Term database for nursing practice in the context of coronavirus (COVID-19) infections.

OBJECTIVE: to build a term database relevant to nursing practice in the context of COVID-19 infections. METHODS: this is a methodological, documentary study, carried out from March to June 2020 at ICNP®/ Universidade Federal da Paraíba center, considered a reference for research and dissemination of ICNP® in Brazil. The findings were collected in databases and analyzed using the PorOnto tool, the consensus technique and the mapping of terms with ICNP®, version 2019/2020. RESULTS: 1,134 relevant terms were identified in literature. When submitted to the mapping technique with the terms of ICNP® Seven Axis Model, it resulted in 531 constant terms and 603 nonconstant terms in this classification. FINAL CONSIDERATIONS: It is proven that nursing practice terms, even in a specific context, are present in the literature and are representative in ICNP®, which will enable the future development of a terminological subset in the context of coronavirus infections.

WebPalestra: consulta de enfermagem à mulher, à criança e à família em processo de amamentação

Resolução COFEN 358/2009; objetivos do processo de enfermagem; fases do processo de enfermagem; terminologia em enfermagem; diagnósticos prevalentes na assistência de enfermagem durante a amamentação.

Mapping nursing practices in rehabilitation units in Spain and the United Kingdom: A multiple case study.

Because of the crisis in the health sector with few employment opportunities, many Spanish nurses are looking for professional development abroad. No studies have mapped nursing practices across Europe. The aim of this research was to provide a comprehensive approach to understand nursing practices and features of the context in Spain and the United Kingdom within the rehabilitation unit and to discuss those practices from a patient safety point of view. Multiple case study design with thematic analysis was applied in this study. The methods for data collection were in-depth interviews, nonparticipant observations, and document analysis. Results were classified into six categories: resources, techniques and nursing procedures, patients' personal care, health education, documentation task, and attitudes and communication skills. This study concludes that differences exist between nursing practices despite both countries having similar nursing competences. In addition, the UK unit has a positive safety culture, recognizes that mistakes happen, and applies more barriers to avoid them. The study provides valuable information to help the decision-making process for Spanish nurses considering working in the UK.

Effectiveness of Nursing Interventions using Standardized Nursing Terminologies: An Integrative Review.

The purpose of this integrative review is to synthesize recent literature that used NANDA International diagnoses, Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) to determine the effectiveness of nursing interventions and cost-analysis and to identify the direction for future effectiveness research using standardized nursing terminologies (SNTs). A search was performed using the Cumulative Index to Nursing and Allied Health Literature, Scopus, and KoreaMed, covering the period from 2003 to 2018. A total 267 articles were identified, and 24 articles were analyzed for this review. Eighteen studies evaluated the effectiveness of nursing interventions based on outcomes, and of those 18 studies, four examined the effectiveness based on the development of NNN linkages. Six studies analyzed the cost of nursing interventions. Integrating SNTs into electronic health records (EHRs), developing NNN linkages, and further effectiveness studies using SNTs are required to determine the value of nursing care to improve patient outcomes.

ICNP ® nursing diagnoses, outcomes and interventions for community elderly.

OBJECTIVE: To construct a nomenclature of nursing diagnoses, outcomes and interventions for elderly people under follow-up in the Family Health Strategy by using the International Classification for Nursing Practice and the theoretical reference of Virginia Henderson. METHOD: Methodological study developed according to guidelines of the International Council of Nurses. RESULTS: A total of 127 concepts of nursing diagnoses/outcomes were constructed and distributed according to nursing care components in the subcategories of Biological/Physiological, Psychological, Social and Spiritual/Moral components. For these diagnoses, were proposed 551 nursing interventions. CONCLUSION: The concepts constructed may favor integral care for the elderly in the Family Health Strategy and the structuring of a terminological subset for this clientele.

ICNP ® nursing diagnoses, outcomes and interventions for community elderly / Diagnósticos, resultados e intervenciones de enfermería de la CIPE ® para ancianos comunitarios / Diagnósticos, resultados e intervenções de enfermagem da CIPE ® para idosos comunitários

ABSTRACT Objective: To construct a nomenclature of nursing diagnoses, outcomes and interventions for elderly people under follow-up in the Family Health Strategy by using the International Classification for Nursing Practice and the theoretical reference of Virginia Henderson. Method: Methodological study developed according to guidelines of the International Council of Nurses. Results: A total of 127 concepts of nursing diagnoses/outcomes were constructed and distributed according to nursing care components in the subcategories of Biological/Physiological, Psychological, Social and Spiritual/Moral components. For these diagnoses, were proposed 551 nursing interventions. Conclusion: The concepts constructed may favor integral care for the elderly in the Family Health Strategy and the structuring of a terminological subset for this clientele.

RESUMEN Objetivo: Construir una nomenclatura de diagnósticos, resultados e intervenciones de enfermería para ancianos acompañados en la Estrategia Salud de la Familia, utilizando la Clasificación Internacional para la Práctica de Enfermería y el referencial teórico de Virginia Henderson. Método: Estudio metodológico desarrollado conforme a las directrices preconizadas por el Consejo Internacional de Enfermeros. Resultados: Se construyeron 127 conceptos de diagnósticos/resultados de enfermería, distribuidos según componentes de los cuidados de enfermería en las subcategorías de los Componentes Biológicos/Fisiológicos, Psicológicos, Sociales y Espirituales/Morales. Para estos diagnósticos se propusieron 551 intervenciones de enfermería. Conclusión: Los conceptos construidos pueden favorecer el cuidado integral a los ancianos en la Estrategia Salud de la Familia, y la estructuración de un subconjunto terminológico para esa clientela.

RESUMO Objetivo: Construir uma nomenclatura de diagnósticos, resultados e intervenções de enfermagem para pessoas idosas acompanhadas na Estratégia Saúde da Família, utilizando a Classificação Internacional para a Prática de Enfermagem e o referencial teórico de Virginia Henderson. Método: Estudo metodológico, desenvolvido conforme as diretrizes preconizadas pelo Conselho Internacional de Enfermeiros. Resultados: Foram construídos 127 conceitos de diagnósticos/resultados de enfermagem, distribuídos segundo componentes dos cuidados de enfermagem, nas subcategorias dos Componentes Biológicos/Fisiológicos, Psicológicos, Sociais e Espirituais/Morais. Para esses diagnósticos foram propostas 551 intervenções de enfermagem. Conclusão: Espera-se que os conceitos construídos possam favorecer o cuidado integral à pessoa idosa na Estratégia Saúde da Família e a estruturação de um subconjunto terminológico para essa clientela.

Plataforma PEnsinar®: a learning tool for teaching the nursing process.

OBJECTIVE: to describe the construction and transition phases undertaken in the development of a virtual learning environment named Plataforma PEnsinar® (PEnsinar Platform®). This platform aims at teaching the nursing process and the nursing classifications NANDA International, NIC, NOC and ICNP®. METHOD: this is a methodological and technological development research that used construction and transition phases of the software development process named Rational Unified Process. RESULTS: the software was developed in the construction phase. Unit and integration tests of components of interfaces were held. In the transition phase, the complete system was showed to the users. It was completely working considering the applicability and employment, under conditions to be implemented and evaluated. CONCLUSION: the study showed how the construction and transition phases of the Plataforma PEnsinar® were developed. It was based on a proposal that inserts the student as an active agent in the nursing process and the professor as a mediator, providing tools that will contribute to a better learning.

Nurse managers' perspectives on nurses' performance in mentorship program

Objective: The aim of this study was to explore the nurse managers' perspectives on nurses' performance in a mentorship program. Method: A cross-sectional survey was conducted on 51 nurse managers in Hospital Tengku Ampuan Afzan (HTAA), Kuantan, Pahang, by using modified and self-developed questionnaire with the Cronbach's alpha value 0.994. The data were analyzed by using descriptive statistics such as central tendency, frequency and percentage. Results: The gender of respondents was predominantly female (100%). The mean age is 45.41 (SD ± 4.51). In terms of level of education, the majority of the respondents (76.5%) were having a diploma. The majority has been in practice as a staff nurse between 11 to 20 years, and most of them have been practicing as nurse managers for about five years and less. Meanwhile, results showed that the nurse managers had positive perceptions upon newly graduated nurses' performance in the mentorship program, concerning on their effective communication, professional development and creative thinking. Conclusions: It is vital to identify the effectiveness of the mentorship program among nurses; hence, it enhances job satisfaction among new nurses

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Catálogo CIPE® para pacientes adultos em processo de neurorreabilitação / ICNP® catalog for adult patients in Neurorehabilitation process

Introdução: A neurorreabilitação é identificada, como um importante componente no processo saúde-doença de pessoas com deficiência, condição cada vez mais complexa e diversificada. O Processo de Enfermagem é uma ferramenta metodológica que deve ser utilizada para direcionar os cuidados prestados a essa população e para utilizá-la é recomendado o uso de uma terminologia unificada, capaz de possibilitar, aos enfermeiros codificar, armazenar e recuperar a informação em um formato que possa ser útil e aplicável na assistência ao paciente. Objetivo: construir um Catálogo de conceitos da Classificação Internacional para a Prática de Enfermagem (CIPE®) na neurorreabilitação de adultos. Método: Trata-se de um estudo metodológico desenvolvido em quatro etapas: composição dos enunciados de diagnósticos / resultados e intervenções de enfermagem; construção de definições operacionais para os enunciados dos diagnósticos / resultados de enfermagem; validação de conteúdo dos enunciados e das definições operacionais dos diagnósticos/resultados de enfermagem e dos enunciados das intervenções de enfermagem junto a enfermeiros especialistas na área; organização do Catálogo de acordo com o Modelo de Adaptação de Roy. Resultados: Foram construídos 1490 enunciados, sendo 394 diagnósticos/resultados de enfermagem e 1090 intervenções de enfermagem. Validou-se quanto ao conteúdo 266 diagnósticos/resultados de enfermagem e 540 intervenções. Os enunciados foram alocados nos modos do Modelo de Adaptação de Roy, sendo 20 diagnósticos/resultados e as intervenções de enfermagem no modo desempenho de papel, 10 diagnósticos/resultados e suas intervenções de enfermagem no modo interdependência; 52 no modo autoconceito e, 184 no modo fisiológico. Conclusão: desenvolveu-se um Catálogo CIPE® para Adultos em processo de neurorreabilitação à luz do modelo teórico de adaptação de Roy. Diagnósticos / resultados e intervenções de enfermagem foram propostos e validados e para ajudar o raciocínio clínico do enfermeiro. Este foi julgado como refletindo as demandas que a população pode apresentar durante o processo de neurorreabilitação e seu uso dará suporte à documentação sistemática do cuidado clínico de enfermagem, usando a CIPE® como terminologia de referência. A CIPE® tem sido considerada uma classificação versátil pois se adapta às muitas realidades e singularidades da prática de enfermagem. Neste sentido, acredita-se que esse Catálogo possa ser usado por enfermeiros reabilitadores na sua prática, padronizando a linguagem empregada e contribuindo com o processo de tomada de decisão clínica.(AU)

Introduction: Neurorehabilitation is identified as an important component in the healthdisease process of people with disabilities, an increasingly complex and diversified condition. The Nursing Process is a methodological tool that should be used to direct the care provided to this population and to use it, it is recommended to use a unified terminology, capable of enabling nurses to code, store and retrieve information in a format which may be useful and applicable in patient care. Objective: to construct a Catalog of concepts of the International Classification for Nursing Practice (CIPE®) in adult neuro-rehabilitation. Method: It is a methodological study developed in four stages: composition of the statements of diagnoses / results and nursing interventions; construction of operational definitions for statements of nursing diagnoses / results; validation of contents of statements and operational definitions of nursing diagnoses / results and statements of nursing interventions with specialist nurses in the area; organization of the Catalog according to Roy's Adaptation Model. Results: A total of 1490 statements were constructed, being 394 nursing diagnoses / results and 1096 nursing interventions. 266 nursing diagnoses / results and 540 interventions were validated. The statements were allocated in the Roy Adaptation Model modes, with 20 diagnoses / results and the nursing interventions in paper performance mode, 10 diagnoses / results and their nursing interventions in the interdependence mode; 52 in the self-concept mode, and 184 in the physiological mode. Conclusions: a CIPE® Catalog for Adults in the process of neurorehabilitation was developed in light of Roy's theoretical model of adaptation. Diagnoses / outcomes and nursing interventions were proposed and validated and should enhance the nurses' clinical reasoning. This was judged as reflecting the demands that the population may present during the neuro-rehabilitation process and its use will support the systematic documentation of clinical nursing care, using CIPE® as a reference terminology. CIPE® has been considered a versatile classification because it adapts to the many realities and singularities of nursing practice. In this sense, it is believed that this Catalog can be used by rehabilitation nurses in their practice, standardizing the language used and contributing to the clinical decision-making process.(AU)

Construção de um banco de títulos de diagnósticos e prescrições de enfermagem para a assistência materno-infantil / Construction of a nursing diagnosis labels and plan care for maternal-child care

A Enfermagem é uma profissão complexa e o seu cuidado é essencial para o tratamento de pessoas enfermas. Na prática assistencial percebe-se a necessidade de instrumentalizar os enfermeiros para implementar o Processo de Enfermagem de forma efetiva e com ações sistematizadas. Este estudo teve por objetivo construir banco de diagnósticos e prescrições de enfermagem para a linha de cuidado materno-infantil. Trata-se de um estudo metodológico realizado em um hospital de ensino de Belo Horizonte, a população/amostra foi constituída por 28 enfermeiros, com predomínio de especialistas do sexo feminino(96,4%) e média de formação de 11,4 anos. Foram analisados 328 formulários com problemas de enfermagem identificados pelos enfermeiros. Após exclusão das repetições e normalização de conteúdo chegou-se a 47 problemas de enfermagem relacionados aos neonatos que após o mapeamento originou a 42 títulos de diagnósticos de enfermagem(DE) e 59 problemas de enfermagem referentes as gestantes/puérpera, que foram mapeados a 57 títulos de DE. Os títulos DE foram organizados às Necessidades Humanas Básicas .Para os neonatos obtiveram-se 100% referentes às necessidades psicobiológicas,sendo a maioria(19%) relacionados à integridade física e cutâneo mucosa; seguido de (14,3%) à regulação vascular. Para as gestantes/puérperas,66,7% dos DE referiam-se às necessidades psicobiológicas sendo,(14%) relacionados à necessidade de integridade física e cutâneo mucosa e 33,3% às necessidades psicossociais com predomínio da necessidade de amor, afeto e atenção(12,3%).Foram identificadas para os DE referentes aos neonatos 284 prescrições de enfermagem, com média de 6,8 prescrições por diagnóstico. Para as gestantes/puérperas foram identificadas 404 prescrições de enfermagem para os 57 títulos de DE,com média de 7,1 prescrições por diagnóstico.O uso de linguagem padronizada pela enfermagem possibilita maior visibilidade à prática clinica do profissional na atenção obstétrica à gestante/puérpera e neonatos.(AU)

Nursing is a complex profession and its care is essential tothetreatment of sick people.Itis noticedthat,in assistivepractice, theneedtoteachthenurses toimplement theNursingProcesses effectively andsystematized. This studyaimedtobuildthenursingdiagnosis labels andplancare for maternal-childcare. This is amethodological studydevelopedat ateachinghospital in Belo Horizonte. The samplepopulationwas of28nurses,withthepredominanceof female specialists(96.4%) andanaveragegraduationof11.4years. Itwas analyzed328instruments withnursingproblems identifiedbynurses.After redundant content'sexclusionandnormalization, 47neonate-relatednursingproblemsand59related-pregnant/puerperal womenwere mappedto42nursingdiagnosis (ND) labelsrelatedtoneonates and57relatedtopregnant/puerperal women. TheNDlabelswere organizedintotheBasic HumanNeedstheoryandforneonates, 100% werepsychobiological humanneeds. Themajority(19%)wererelatedtophysical andcutaneousphysical integrity, followedby(14.3%) tovascular regulation. Forpregnant/puerperal women, 66.7% oftheNDreferredtothepsychological need,being(14%) relatedtophysicalintegrityandcutaneousandmucosalintegritybasic ehumanneeds.33.3%referredtopsychosocial needs withrespecttolove, affectionandattention(12.3%)needs. Atotal of284nursingcare prescriptionswithanaverageof6.8per diagnostic were identifiedfor neonates and404nursingcare prescriptionswere identifiedfor pregnant/puerperalwomen,withanaverageof7.1requirements per nursingdiagnoses.Theuseofanursingstandardizedlanguageallowsgreater visibilitytoprofessional's clinical practiceinobstetric carefor pregnant/puerperal women andneonates.

Plataforma PEnsinar®: a learning tool for teaching the nursing process / Plataforma PEnsinar®: herramienta de aprendizaje para la enseñanza del proceso de enfermería / Plataforma PEnsinar®: ferramenta de aprendizagem para o ensino do processo de enfermagem

ABSTRACT Objective: to describe the construction and transition phases undertaken in the development of a virtual learning environment named Plataforma PEnsinar® (PEnsinar Platform®). This platform aims at teaching the nursing process and the nursing classifications NANDA International, NIC, NOC and ICNP®. Method: this is a methodological and technological development research that used construction and transition phases of the software development process named Rational Unified Process. Results: the software was developed in the construction phase. Unit and integration tests of components of interfaces were held. In the transition phase, the complete system was showed to the users. It was completely working considering the applicability and employment, under conditions to be implemented and evaluated. Conclusion: the study showed how the construction and transition phases of the Plataforma PEnsinar® were developed. It was based on a proposal that inserts the student as an active agent in the nursing process and the professor as a mediator, providing tools that will contribute to a better learning.

RESUMEN Objetivo: describir las etapas de construcción y transición realizadas en el desarrollo de un ambiente virtual de aprendizaje (Plataforma PEnsinar®) destinado para la enseñanza del proceso de enfermería y de las clasificaciones Nanda Internacional, NIC, NOC y CIPE®. Método: se trata de una investigación metodológica y de desarrollo tecnológico que utilizó las etapas de construcción y transición del proceso de desarrollo de programa (software): Rational Unified Process. Resultados: en la etapa de construcción fue desarrollado el software y se ejecutaron las pruebas unitarias e integradas de los componentes de las interfaces. En la transición, se mostró a los usuarios el sistema completo y en funcionamiento para la aplicabilidad y el empleo, en condiciones de ser implementado y evaluado. Conclusión: el estudio mostró como fue desarrollada la construcción y la transición de la Plataforma PEnsinar®, basada en una propuesta que inserta el discente cómo agente activo en el proceso de enfermería, y el docente como mediador, suministrando las herramientas que posibilitarán un mejor aprendizaje.

RESUMO Objetivo: descrever as etapas de construção e transição realizadas no desenvolvimento de um ambiente virtual de aprendizagem (Plataforma PEnsinar®) voltado para o ensino do processo de enfermagem e das classificações Nanda Internacional, NIC, NOC e CIPE®. Método: trata-se de uma pesquisa metodológica e de desenvolvimento tecnológico que utilizou as fases de construção e transição do processo de desenvolvimento de software: Rational Unified Process. Resultados: na fase de construção foi desenvolvido o software e executaram-se os testes unitários e integrados dos componentes das interfaces. Na transição, mostrou-se aos usuários o sistema completo e em funcionamento para a aplicabilidade e emprego, em condições de ser implementado e avaliado. Conclusão: o estudo mostrou como foi desenvolvida a construção e transição da Plataforma PEnsinar®, baseada em uma proposta que insere o discente como agente ativo no processo de enfermagem, e o docente como mediador, fornecendo ferramentas que possibilitarão um melhor aprendizado.

Embedding Nursing Interventions into the World Health Organization's International Classification of Health Interventions (ICHI).

OBJECTIVE: The International Classification of Health Interventions, currently being developed, seeks to span all sectors of the health system. Our objective was to test the draft classification's coverage of interventions commonly delivered by nurses, and propose changes to improve the utility and reliability of the classification for aggregating and analyzing data on nursing interventions. MATERIALS AND METHODS: A 2-phase content mapping method was used: (1) three coders independently applied the classification to a dataset comprising 100 high-frequency nursing interventions; (2) the coders reached consensus for each intervention and identified reasons for initial discrepancies. RESULTS: A consensus code was found for 80 of the 100 source terms; for 34% of these, the code was semantically equivalent to the source term, and for 64% it was broader. Issues that contributed to discrepancies in Phase 1 coding results included concepts in source terms not captured by the classification, ambiguities in source terms, and uncertainty of semantic matching between "action" concepts in source terms and classification codes. DISCUSSION: While the classification generally provides good coverage of nursing interventions, there remain a number of content gaps and granularity issues. Further development of definitions and coding guidance is needed to ensure consistency of application. CONCLUSION: This study has produced a set of proposals concerning changes needed to improve the classification. The novel method described here will inform future health terminology and classification content coverage studies.

Reflections in the light of the complexity theory and nursing education. / Reflexões à luz da Teoria da Complexidade e a formação do enfermeiro.

OBJECTIVE:: to reflect on nursing education, taking into account the principles of complex thinking proposed by Morin. METHOD:: reflection based on the principles of the complexity theory by Edgar Morin. RESULTS:: the application of complexity in teaching proposes an emancipatory education based on questioning and social transformation. It comprises the education of nurses who interact with others as a characteristic of their work. It is necessary to prepare students to develop critical and reflective attitudes and actions to overcome the fragmentation and linearity of knowledge. CONCLUSION:: nursing care has been based on a reductionist assistance, reflecting the Cartesian model. Thus, nursing education seeks to comprise shared knowledge and experiences so that no subject or professional overpowers another, accepting the uniqueness of professionals and patients.

Reflexões à luz da Teoria da Complexidade e a formação do enfermeiro / Reflexiones a la luz de la Teoría de la Complejidad y la formación del enfermero / Reflections in the light of the complexity theory and nursing education

RESUMO Objetivo: refletir sobre a formação em Enfermagem levando em consideração os princípios do pensar complexo proposto por Morin. Método: reflexão fundamentada nos princípios da Teoria da Complexidade de Edgar Morin. Resultados: a aplicação da complexidade no ensino propõe uma educação emancipadora pautada no questionamento e na transformação social. Compreende a formação de enfermeiros que tenham como característica do seu trabalho a interação com o outro. Faz-se necessário preparar o discente para desenvolver atitudes e ações críticas e reflexivas capazes de superar a fragmentação e a linearidade do conhecimento. Conclusão: o cuidado de Enfermagem tem sido baseado numa assistência reducionista, refletindo o modelo cartesiano. Assim, a formação do enfermeiro busca contemplar saberes e experiências compartilhados de maneira que não exista o domínio de nenhuma disciplina sobre as outras, de nenhum profissional sobre o outro, aceitando as singularidades tanto dos profissionais como do próprio cliente/paciente.

RESUMEN Objetivo: reflexionar sobre la formación en Enfermería teniendo en consideración los principios del pensar complejo propuesto por Morin. Método: reflexión fundamentada en los principios de la Teoría de la Complejidad de Edgar Morin. Resultados: la aplicación de la complejidad en la enseñanza propuesta una educación emancipadora pautada en el cuestionamiento y en la transformación social. Comprende la formación de enfermeros que tengan como característica de su trabajo la interacción con el otro. Se hace necesario preparar al aprendiz para desarrollar actitudes y acciones críticas y reflexivas capaces de superar la fragmentación y la linealidad del conocimiento. Conclusión: el cuidado de Enfermería ha sido basado en una asistencia reduccionista, reflexionando el modelo cartesiano. Así, la formación del enfermero busca contemplar saberes y experiencias compartidas de manera que no exista el dominio de ninguna disciplina sobre las otras, de ningún profesional sobre otro, aceptando las singularidades tanto de los profesionales como del propio cliente/paciente.

ABSTRACT Objective: to reflect on nursing education, taking into account the principles of complex thinking proposed by Morin. Method: reflection based on the principles of the complexity theory by Edgar Morin. Results: the application of complexity in teaching proposes an emancipatory education based on questioning and social transformation. It comprises the education of nurses who interact with others as a characteristic of their work. It is necessary to prepare students to develop critical and reflective attitudes and actions to overcome the fragmentation and linearity of knowledge. Conclusion: nursing care has been based on a reductionist assistance, reflecting the Cartesian model. Thus, nursing education seeks to comprise shared knowledge and experiences so that no subject or professional overpowers another, accepting the uniqueness of professionals and patients.

Advanced Nursing Process quality: Comparing the International Classification for Nursing Practice (ICNP) with the NANDA-International (NANDA-I) and Nursing Interventions Classification (NIC).

AIMS AND OBJECTIVES: To assess the quality of the advanced nursing process in nursing documentation in two hospitals. BACKGROUND: Various standardised terminologies are employed by nurses worldwide, whether for teaching, research or patient care. These systems can improve the quality of nursing records, enable care continuity, consistency in written communication and enhance safety for patients and providers alike. DESIGN: Cross-sectional study. METHODS: A total of 138 records from two facilities (69 records from each facility) were analysed, one using the NANDA-International and Nursing Interventions Classification terminology (Centre 1) and one the International Classification for Nursing Practice (Centre 2), by means of the Quality of Diagnoses, Interventions, and Outcomes instrument. Quality of Diagnoses, Interventions, and Outcomes scores range from 0-58 points. Nursing records were dated 2012-2013 for Centre 1 and 2010-2011 for Centre 2. RESULTS: Centre 1 had a Quality of Diagnoses, Interventions, and Outcomes score of 35·46 (±6·45), whereas Centre 2 had a Quality of Diagnoses, Interventions, and Outcomes score of 31·72 (±4·62) (p < 0·001). Centre 2 had higher scores in the 'Nursing Diagnoses as Process' dimension, whereas in the 'Nursing Diagnoses as Product', 'Nursing Interventions' and 'Nursing Outcomes' dimensions, Centre 1 exhibited superior performance; acceptable reliability values were obtained for both centres, except for the 'Nursing Interventions' domain in Centre 1 and the 'Nursing Diagnoses as Process' and 'Nursing Diagnoses as Product' domains in Centre 2. CONCLUSION: The quality of nursing documentation was superior at Centre 1, although both facilities demonstrated moderate scores considering the maximum potential score of 58 points. Reliability analyses showed satisfactory results for both standardised terminologies. RELEVANCE TO CLINICAL PRACTICE: Nursing leaders should use a validated instrument to investigate the quality of nursing records after implementation of standardised terminologies.

Is the ISO Reference Terminology Model for Nursing Actions Enough to Describe Nursing Actions?

The aim of this study is to test the applicability of the International Standards Organization (ISO) Reference terminology model (RTM) for nursing action to describe Detailed Clinical Models (DCMs) for nursing action. All verb and target terms were mapped to 'Action' and 'Target' category of RTM for nursing actions. Among 72 attributes qualifying the verb terms, 50 attributes were mapped to Means, Route, Timing, or Site categories of the nursing action model. Among 142 attributes qualifying the target terms, 20 attributes were mapped to Means, Timing, or Site categories of the nursing action model and 6 attributes were mapped to Degree or Judgment categories of the nursing diagnosis model. The findings suggest the need for an integrated RTM for nursing.

Intervenções de Enfermagem para idosos que envelheceram em instituições psiquiátricas: mapeamento cruzado / Nursing interventions for elderly who aged in psychiatric institutions: crossed mapping

Objetivou-se realizar o mapeamento cruzado de termos da linguagem de Enfermagem com o sistema de Classificação das Intervenções de Enfermagem, em prontuários de idosos com transtornos psiquiátricos.Trata-se depesquisa documental, de mapeamento cruzado, com amostra intencional, composta por 30 prontuários de idosas com transtornos psiquiátricos. A coleta e a análise ocorreram entre julho de 2013 a maio de 2014, em três etapas. Foram encontradas 392 intervenções normalizadas, que resultaram em 33 intervenções, média de 13 por usuários, representadas por 15 intervenções do domínio comportamental e 10 do fisiológico básico. ͞Orientação para a realidade͟, ͞Melhora da socialização͟, ͞ Assistência no autocuidado: atividades essenciais da vida diária͟e ͞Apoio familiar͟ estiveram em 100% dos prontuários. Foram descritas 16 atividades por intervenção. O mapeamento cruzado permitiu construir termos correspondentes às Intervenções de Enfermagem cotidianas em saúde mental, contribuindo para a prática assistencial.

Our objective was to cross map terms of Nursing language with the system of Nursing Interventions Classifications, in records of elderly with psychiatric disorders. This is a cross mapping documental study with an intentional sample composed by 30 records of elderly with psychiatric disorders. The data collection and analysis were conducted from July of 2013 to May of 2014, in three steps. We found 392 normalized interventions that resulted in 33 interventions, a mean of 13 per user, represented by 15 behavioral interventions and 10 of basic physiology domain. ͞Reality orientation͟, ͞Socialization enhancement͟, ͞Self-care assistance: instrumental activities of daily living͟ and ͞Family support͟ were in 100% of records. We described 16 activities per intervention. Crossed mapping allowed us to build terms corresponding to routine Nursing Interventions for mental health, contributing for assistance practice

Harmonizing Nursing Terminologies.

In this paper, the authors report on a study aimed at harmonising two nursing terminologies, the Clinical Care Classification (CCC) and the International Classification for Nursing Practice (ICNP®). As the electronic health record evolves and the need for interoperability extends beyond local and national borders, a degree of standardisation across healthcare terminologies become essential. Harmonising across terminologies results in a) increased consensus relating to domain content and b) improvements in the terminologies involved. Findings from this study suggest that there is much overlap of content in nursing terminologies. The continued harmonisation between nursing terminologies and other healthcare terminologies are recommended to achieve international interoperability.

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.

Validación de la versión en castellano del Nursing Activities Score / Validating the Spanish version of the Nursing Activities Score

Introducción: Validar las escalas es necesario para garantizar que son apropiadas para el objetivo para el que fueron creadas. Objetivo: Validar la versión en castellano del Nursing Activities Score (NAS). Metodología: Estudio observacional y prospectivo que incluye a 1.045 pacientes ingresados en una unidad médico-quirúrgica y una unidad de grandes quemados en 2006. La enfermera encargada del paciente valoró cargas de trabajo mediante el Nine Equivalent of Nursing Manpower use Score y el NAS. Para evaluar la consistencia interna de las mediciones del NAS se calcularon las correlaciones ítem-test, el alfa de Cronbach y alfa de Cronbach corregido, al omitir cada uno de los ítems. La fiabilidad intraobservador y la interobservador se valoraron con el coeficiente de correlación intraclase mediante la visualización de grabaciones y el Kappa (fiabilidad interobservador). Para analizar la validez interna se realizó un análisis factorial de componentes principales, y para la convergente el coeficiente de correlación de Spearman de los valores obtenidos de las escalas Nine Equivalent of Nursing Manpower use Score y NAS-castellano. Resultados: Para la consistencia interna se analizaron 164 cuestionarios calculando un alfa de Cronbach de 0,373. El coeficiente de correlación intraclase para la estimación de la fiabilidad intraobservador fue 0,837 (IC 95%: 0,466-0,950) y 0,662 (IC 95%: 0,033-0,882) para la fiabilidad interobservador. El kappa estimado fue 0,371. Para la validez interna, el análisis factorial exploratorio mostró que el primer ítem explicaba el 58,9% de la varianza del cuestionario. Para la validez convergente se incluyeron 1.006 cuestionarios y se observó un coeficiente de correlación de Spearman de 0,746. Conclusiones: Las propiedades psicométricas del NAS-castellano son aceptables

Introduction: Validating workload scores ensures that they are appropriate for the purpose for which they were developed. Objective: To validate the Nursing Activities Score (NAS) Spanish version. Methodology: Observational and prospective study. 1,045 patients who were admitted to a medical-surgical unit and a serious burns unit in 2006 were included. The nurse in charge assessed patient workloads by Nine Equivalent of Nursing Manpower use Score and NAS. To assess the internal consistency of the measurements of NAS, item-test correlations, Cronbach's alfa and Cronbach's alfa corrected by omitting each of the items were calculated. The intraobserver and interobserver reliability were assessed with the intraclass correlation coefficient by viewing recordings and Kappa (interobserver reliability) was estimated. For the analysis of internal validity, a factorial principal components analysis was performed. Convergent validity was assessed using the Spearman correlation coefficient values obtained from the Nine Equivalent of Nursing Manpower use Score and Spanish-NAS scales. Results: For internal consistency, 164 questionnaires were analysed and a Cronbach's alfa of 0.373 was calculated. The intraclass correlation coefficient for intraobserver reliability estimate was 0.837 (95% IC: 0.466-0.950) and 0.662 (95% IC: 0.033-0.882) for interobserver reliability. The estimated kappa was 0.371. For internal validity, exploratory factor analysis showed that the first item explained 58.9% of the variance of the questionnaire. For convergent validity 1006 questionnaires were included and a Spearman correlation coefficient of 0.746 was observed. Conclusions: The psychometric properties of Spanish-NAS are acceptable