International Classification For Nursing Practice Research Articles

Development and validation of detailed clinical models for nursing actions in perinatal care

ObjectivesThe aim of this study was to develop and evaluate detailed clinical models (DCMs) for nursing actions in perinatal care. We propose the use of action-target dyads as entities in DCMs for nursing actions. MethodsWe identified action and target concepts, attributes, and value sets by analyzing nursing documentation and reviewing the wider literature, in addition to published standards and models. We developed the DCMs by linking entities, attributes, and value sets. DCMs were classified by action type based on the Clinical Care Classification, and by target type based on the axes of the International Classification for Nursing Practice (ICNP). Attributes in the DCMs were also classified by ICNP axes. The quality of the DCMs was evaluated by domain experts, and their coverage was evaluated by mapping narrative nursing statements. ResultsNursing DCMs consisting of 233 entities (dyads comprising 34 action and 212 target concepts), 214 attributes and 541 values were developed. The most frequent action type was hands-on care (43.3%). The focus axis was used most frequently for the targets (51.9%) and attributes (38.8%). The quality scores of the DCMs ranged from 0.80 to 0.96. Most (174/192; 90.6%) of the statements were fully mapped, while 7 (3.7%) were partially mapped and 11 (5.7%) were not mapped. We modified the DCMs in accordance with these results. ConclusionsIn total, 240 DCMs were developed with action-target dyads as entities. The DCMs developed in this study could be implemented in an electronic nursing record system to enhance nursing practices and ensure semantic interoperability of nursing data.

Specifics in the review of health documentation.

The objective of the work was to identify if health documentation management is depending of actually current legislation. Also to review range and consistency records. The work described forms and content of documentation, relating to treat wounds and decubitus. A content analysis of 139 health documentation of insurer of General Health Insurance Company, which were treated by 28 home care agencies (hereinafter "HCA") and in the HCA was done directly audit in 2012 and 2014. We set 29 assessment items, with criteria separation according structure, process and outcome. Documentation, we analyzed three ways: through 5 grade rating scale, by choosing a clear answer to the question: yes, no and evaluation of specific items of documentation. The research confirm dependence keeping medical records in home nursing care agencies from legislation. On the other hand, it was found that the form of the recording method of health care in many cases are varied and fragmented. Deficiencies were found in the area of criteria such as structure, process and outcomes and transparency in the management of documentation pressure ulcers and chronic wounds. Only 62.9 % of the documentations was written nursing care and sent to Health Insurance Company in full compliance or with minor shortcomings. Research has shown that in the legislation defined by standard forms was recorded the lowest number of deficiencies. This fact needs to be used for the development of new legislation, which directed to setting documentation with clearly defined, structured information's. WHO adopted the International Classification for Nursing Practice (ICNP) as essential and complementary part of professional health services (Tab. 2, Fig. 2, Ref. 22).

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

To assess the quality of the advanced nursing process in nursing documentation in two hospitals. 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. Cross-sectional study. 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. 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. 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. Nursing leaders should use a validated instrument to investigate the quality of nursing records after implementation of standardised terminologies.

Harmonising ICNP and SNOMED CT: A Model for Effective Collaboration.

The purpose of this panel was to demonstrate an approach to collaborative working within nursing and health informatics. The panel took as an example an initiative to harmonise between two large-scale terminologies, namely the International Classification for Nursing Practice (ICNP) and SNOMED Clinical Terms (SNOMED CT). A number of practical topics were framed within a context of collaboration, including semi-automated and manual approaches to mapping, consensus working, clinical validation, formal concept modelling, etc. Those attending the panel, nurses and informatics professional alike, came away with an increased understanding of a range of approaches to collaborative working within nursing and health informatics.

The International Classification for Nursing Practice (ICNP®) in the Nursing Consultation to the Puerperal Woman

Introduction: The International Classification for Nursing Practices (ICNP) articulated to the Systematization of Nursing Assistance (SNA) in the puerperal consultation is necessary in view of the importance of offering quality care for mother and child. Objective: Discuss the contributions that ICNP ® brings to the nursing consultation and the quality of care to the puerperal woman. Method: This is a descriptive, qualitative study, the integrative review type, performed by the BDENF and LILACS databases. Results: The databases returned 45 publications, but only 10 responded to the proposed objective of the study. Discussion: The collected data were analyzed and point to the importance of conducting effective interventions for the monitoring of puerperal women and children. Another observed point was the deficit in the knowledge of nursing professionals on the ICNP. Conclusion: Thus, one understands that using SNA and implementing ICNP enable the strengthening of the unified language, favoring the assistance in a universal way and, therefore, a better quality of health of the population.

Shaping Nursing Professional Skills with the use of the Method of Nursing Process as well as Diagnoses and Nursing Interventions According to ICNP Oriented on the Female Patient with Multiple Sclerosis

Introduction. In order to achieve a learning success by a nurse during the pre- and post-graduate education, it is useful to apply the method of case studies using the International Classification for Nursing Practice (ICNP) or the traditional model of the nursing process.Case Report. The patient in good general condition, with overweight. Nourished orally, the patient shows a standard swallowing reflex. There are appetite disorders. Periodically, there occur constipation and urine retention. The patient shows increased risk of urinary tract infections due to self catheterization. Physical fitness limited because of the paresis of the right lower limb. Body balance impaired. The patient moves with the assistance from one person. She uses auxiliary means to move. On the Barthel Scale the patient scored 50 points, which indicates that she needs assistance in the performance of daily activities.Discussion. In the patient with multiple sclerosis there occurred nursing problems, in particular: reduction of capacity in terms of self-care and self-nursing, difficulty in performing daily activities, difficulty with communicating, urine residual in the bladder, constipation, the possibility of contractures, the possibility of eating disorders, discomfort caused by increased sweating, depressed mood, pain in bones and joints.Conclusions. Referring to diagnoses and ICNP interventions in the process of nursing it has been confirmed that the nursing care of the patient with MS is based on a holistic approach to the patient. All spheres of patient’s life regarding biological, psychological, social, cultural and spiritual aspects were included in it. (JNNN 2015;4(2):76–84)

Appropriateness of ICNP in Korean home care nursing

ObjectivesThere are several hospitals in Korea that introduced the ICNP (International Classification for Nursing Practice) as the standard terminology for clinical and home care nursing. This research attempted to determine the appropriateness of ICNP in Korean, hospital based, home care nursing. MethodsThe data was collected from a home care nursing center from January 1, 2009 to September 21, 2012. The center is operated by a Korean teaching hospital equipped with an ICNP based electronic nursing record (ENR) system. Via a refining process, 40,082 simplified sentences of nursing intervention were acquired from 41,158 nursing records. Among them, 545 preferred nursing statements were extracted, then mapped, to ICNP 2011 at both axis and sentence levels. ResultsThe mapping results were classified into three categories based on the axis of concept origin and the level of hierarchy. These categories were titled: complete, incomplete and no mapping. Out of 45 unique concepts in the action axis, 42 (93.33%) concepts were completely mapped. However, only 38 (15.08%), out of 252 unique concepts, were completely mapped in the focus axis. At the statement level, only 19.63% of statements were completely mapped. ConclusionsThe ICNP is not useful as a tool for home care nursing in its present form. The granularity of ICNP has to be improved and more concepts, specific to home care nursing, need to be added in the focus and action axes. Also, a new measure needs to be introduced to prevent information loss during mapping.

Informatics: The Standardized Nursing Terminologies: A National Survey of Nurses’ Experience and Attitudes—SURVEY II: Participants’ Perception of the Helpfulness of Standardized Nursing Terminologies in Clinical Care

This is the fifth column reporting the results of a survey addressing nurses' attitudes and perceptions regarding standardized nursing terminologies, and completed by the authors in the fall of 2011. Prior columns have examined the demographics of our respondents and their familiarity with the American Nurse?.Association (ANA), standard ized nursing.terminologies (Schwirian & Ih.iad.fi> 2Q12); educational preparation for using the.terminologies, (Thede & Schwirian, 2013b): users perception .of confidence in using the..term in.ologi.es (Ihe.de & Schwirian ,.20.13.0 ; and offsets of documenting with sta nda rdized nursing, terminologies (Thede & Schwirian 20.13a*)In this column, we will report users' opinions about the helpfulness of a terminology in actual clinical practice. The findings presented below are from those respondents who answered 'yes' to the following three questions about the terminology: (a) are you familiar with the terminology?, (b) have you used it in some way?, and (c) have you used this particular terminology in actual patient care?Table 1 and Figure 1 illustrate the percentage of clinical users of a terminology who found the terminology helpful in actual clinical practice.; With the exception of the International Classification of Nursing Practice (ICNP) terminology, for which there were only four responses, more than 60% of clinical users of the nursing-specific terminologies found them helpful in clinical patient care. The Clinical Care Classification (CCC) users and the Omaha System users gave the most positive responses as noted in Table 1. Users of the interdisciplinary terminologies, Logical Observation Identifiers Names and Code (LOINC) and Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT), had the least positive perceptions regarding the helpfulness of the terminology in clinical practice. For the nursing-specific terminologies, North American Nursing Diagnosis Association, International (NANDA-I) and the Nursing Outcomes Classification (NOC) had relatively high percentages of users who did not find the terminology helpful in clinical practice.Tasks for Standardized TerminologiesClinical users of a terminology who answered 'yes' to the question about whether a terminology was helpful in clinical practice were then asked, In what ways was X (the specific terminology) helpful to you? A list of possible choices followed (below). Participants could check as many options as they felt were relevant and could also add other options.* Organizing patient care* Planning care* Generating appropriated outcomes* Generating appropriate interventions* Retrieving information on the same term for many patients* Other (please specify) or commentsTable 2 reports the numbers of respondents who selected each task and the percentage of clinical users of that terminology who found it helpful in that area. The bottom line provides the overall average of the helpfulness of the terminologies for each task/option. If one looks at this data for all the terminologies, planning care (64/1%) was found to benefit most from terminology use while retrieving information was found to benefit the least number of patients, followed closely by organizing patient care (53.7%). Because these terminologies have different foci, the percentages for each task may not be exactly comparable between the terminologies. For this reason, each terminology will be explored separately, along with some 'free text' tasks that respondents entered for that terminology.Nursing Specific TerminologiesMost of the ANA recognized, standardized terminologies are nursing specific; that is, they have more in common with nursing than any of the other health disciplines. This does not mean that they cannot be used in other disciplines; rather it means that they address many specific nursing situations, not only the dependent functions of nursing, but also independent nursing functions. …

Terminological subsets of the International Classification for Nursing Practice - ICNP® for senior patients: a methodological study

Objetivos: Construir enunciados de diagnosticos/resultados e intervencoes de enfermagem para idosos e estruturar um Subconjunto terminologico da CIPE ® para a pessoa idosa no municipio de Joao Pessoa – PB, tendo como suporte teorico o Modelo de Vida. Metodo: Pesquisa metodologica desenvolvida em quatro etapas: identificacao do cliente, coleta de termos e conceitos relevantes para o cliente, elaboracao dos enunciados de diagnosticos/resultados e intervencoes de enfermagem, proposta de um Subconjunto Terminologico da CIPE ® para a pessoa idosa. Resultados: Foram construidos 127 enunciados de diagnosticos e resultados de enfermagem e 617 de intervencoes de enfermagem. Considera-se que os enunciados construidos de diagnosticos/resultados e intervencoes de enfermagem contemplam todos os fatores que influenciam as atividades de vida do idoso. Espera-se que esse Subconjunto seja utilizado como recurso facilitador pelos enfermeiros da Atencao Basica de Saude no cuidado ao idoso no municipio de Joao Pessoa-PB, apos estudo posterior de validacao de conteudo e clinica.

Palliative Care Nursing Interventions in Thailand

This study aimed to describe the nursing interventions that nurses in Thailand identify as most important in promoting dignified dying. This study used a cross-sectional descriptive design. A total of 247 Thai nurses completed a paper-and-pencil survey written in Thai. The survey included both demographic questions and palliative care interventions, listed with summative rating scales, from the International Classification for Nursing Practice (ICNP) catalogue Palliative Care for Dignified Dying. Descriptive statistics were used to analyze the data. The five most important nursing interventions to promote dignified dying, ranked by average importance rating, were (a) maintain dignity and privacy, (b) establish trust, (c) manage pain, (d) establish rapport, and (e) manage dyspnea. This research identified the palliative care nursing interventions considered most important by nurses in Thailand to promote dignified dying. The ICNP catalogue Palliative Care for Dignified Dying can be used for planning and managing palliative nursing care in Thailand.

Child Development in the NANDA‐I and International Classification for Nursing Practices Nursing Classifications*

Identify and analyze the NANDA-I diagnoses and the focus terms of the International Classification for Nursing Practices (ICNP) related to child development. Literature, reflections about clinical experience, and a model case. DATA SYNTHESE: The current diagnoses proposed by NANDA-I and the ICNP focus terms do not encompass the extent of the child development phenomenon. It is necessary studying the child development concept to improve the definition of the ICNP focus terms and the accuracy of NANDA-I diagnoses. Discussing the nursing classifications can improve their understanding and use.

Analysis of Standard Nursing Statement Recorded in Electronic Nursing Record (ENR) System in Kidney Transplant Patients

Background and Purpose: The electronic nursing record (ENR), which includes a nursing process is an important data because it is the evidence of nursing care and nursing effect. Standard nursing statement is a template statement used in ENR system in many centers. But the frequency of standard nursing statement in ENR records, were not studied. The purpose of this study is to analyze the frequency of standard nursing statements used on ENR in kidney transplant (KT) patients. Material and methods: The Data were collected by retrospective review of ENR. 218 kidney transplant patients, whose transplantation was performed between Jan. 2010 and Dec. 2010 in a single center were enrolled. The nursing process statements, recorded in ENR system during admission for transplant surgery, were categorized by the International Classification for Nursing Practice (ICNP). This template was based on ICNP. Results: Total 291,674 nursing process statements were collected which means1337 statement per patients during 15days of admission. Diagnosis category was most frequent statement (33.9%). Five nursing diagnoses contents in the order of frequency were: risk for infection(12.55%), acute pain(11.9%), risk for impaired skin integrity(2.36%), ineffective tissue perfusion(1.77%), and deficient knowledge(1.61%). The greater part of nursing action statements were: assess for factor that increased the risk of infection, education and intervention for prevention of infection, and assessment of the pain. Standard nursing statements investigated the frequency of use as follows: standard nursing assessment statements(26.0%), standard nursing diagnosis statements(42.4%), standard nursing plan statements(26.5%), standard nursing intervention statements(36.2%), and standard nursing evaluation statements(21.6%). Discussion and conclusion: The main contents of ENR system in kidney transplant patient were prevention for infection, and pain management. Aside from these nursing care, succinct standardized nursing record guideline is needed specialized to kidney transplant patient. Education and further modification of standardized guidelines for the ideal nursing record, may be helpful in improving the quality of nursing records. This study will help nurses to perform their nursing processes more efficiently.

ICNP Catalogues for supporting nursing content in electronic health records.

The purpose of this study was to describe sets of nursing concepts including, for example, nursing diagnoses and interventions, which are knowledge-based and clinically relevant to support nursing practice. Health information systems using the International Classification for Nursing Practice (ICNP®) provide a platform for standardized nursing documentation for patients' health care, clinical decision support, and repositories for re-use of clinical data for quality evaluation, research, management decisions and policy development. Clinically relevant sets of ICNP concepts can facilitate implementation of health information systems for nursing. Descriptive analysis was used to examine the types of, and relationships among, existing nursing content sets. Findings included the need for various types of content sets, as represented in ICNP catalogues, for nursing documentation. Five types of ICNP Catalogues included Care Plans, Order Sets, Clinical Templates, Nursing Minimum Data Sets, and Terminology Subsets.

Aplicabilidade da classificação internacional para a prática de enfermagem no Brasil

The present study consists of an integrative review which aimed to survey Brazilian publications that make use of the International Classification for Nursing Practice (ICNP), identify the types of research undertaken on the subject, highlight the ICNP catalogs produced in Brazil and identify the scientific production according to Brazilian states. The descriptors used were Nursing process , Nursing diagnosis and keyword ICNP from 2005 to 2010 on database LILACS and MEDLINE. In the survey 21 studies categorized into three areas were included: research designed to bring up diagnostic and therapeutic interventions according to specific pathologies; Transcript of the language used by nurses cross mapped with the terms included in ICNP; Deployment / Evaluation of the nursing process, with the ICNP as a language of choice. It was not found any ICNP catalog, but research conducted in the context of its creation. It was concluded that it is necessary continued study on this issue in order to spread the use of this language in Brazil and to achieve the creation of catalogs CIPE, which are useful to the nursing process.

Nursing interventions to promote dignified dying in South Korea

This descriptive study aimed to assess the appropriateness of the International Classification for Nursing Practice (ICNP) catalogue Palliative Care for Dignified Dying for palliative care nursing interventions in South Korea. The study surveyed 213 South Korean nurses who might regularly care for dying patients. Nurses were recruited to complete a survey that included interventions from the ICNP catalogue listed with Likert response sets. All of the interventions were scored as being at least 'slightly important' on average. The following three nursing interventions were ranked as most important when caring for dying patients: establish trust, establish rapport, and administer pain medication. The study provides new insights into the palliative care provided in South Korea by documenting nurses' views of what are the most important palliative care nursing interventions. It also suggests that the palliative care interventions listed in the ICNP catalogue Palliative Care for Dignified Dying are in congruence with the interventions that nurses in South Korea use.

Supporting dignified dying in the Philippines

This study aimed to assess the appropriateness of the International Classification for Nursing Practice (ICNP) Palliative Care for Dignified Dying catalogue for palliative nursing in the Philippines. The study recruited 230 nurses to complete the ICNP Dignified Dying survey. Participants rated ICNP nursing intervention items and identified additional interventions for promoting dignified dying. All of the intervention items were scored on average as being at least 'slightly important'. The three top-ranked nursing intervention categories were providing social support, maintaining privacy boundaries, and relieving psychological distress. The ICNP Palliative Care for Dignified Dying catalogue lists nursing interventions that are appropriate to promoting dignity at the end of life in the Philippines.

Toward harmonising WHO International Classifications: a nursing perspective

The WHO Family of International Classifications (FIC) provides a suite of health classifications to promote data exchange and comparisons worldwide. The International Classification of Functioning, Disabilities and Health (ICF) and the International Classification for Nursing Practice (ICNP) are part of WHO-FIC. This study was designed to examine to what extent the ICF and ICNP could be mapped to facilitate unambiguous communication across health settings and professionals. A total of 946 concepts from ICF were mapped to ICNP primitive concepts. Lexical matches generated by machine were examined to find false positive or additional semantic equivalence. Although the semantic mapping increased the number of exact and partial matches by 13%, only less than half of ICF concepts (46%) were able to be mapped to ICNP concepts. ICF concepts were more granular than ICNP concepts in the area of human functioning and body structures. Major challenges in mapping the two classifications resulted from differences in the terminology structure, concept representation and content specificity. A reference terminology model was useful to the mapping effort. The study findings support ongoing advancement in the area of harmonisation of healthcare terminologies. Applications that blend the use of ICF and ICNP concepts in practice should be further tested.

Exploring the Possibility of Information Sharing between the Medical and Nursing Domains by Mapping Medical Records to SNOMED CT and ICNP

ObjectivesThe purpose of this study is to explore possibility of information sharing between the medical and nursing domains.MethodsNarrative medical records of 281 hospitalization days of 36 gastrectomy patients were decomposed into single-meaning statements. These single-meaning statements were combined into unique statements by removing semantically redundant statements. Concepts from the statements describing patients' problem and medical procedures were mapped to Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) and International Classification for Nursing Practice (ICNP) concepts.ResultsA total 4,717 single-meaning statements were collected and these single-meaning statements were combined into 858 unique statements. Out of 677 unique statements describing patients' problems and medical procedures, about 85.5% statements were fully mapped to SNOMED CT. The remaining statements were partially mapped. In the mapping to the ICNP concepts, 17.4% of unique statements were fully mapped, 62.8% were partially mapped, and 19.8% were not mapped. About 32.3% of 705 concepts extracted from the statements were mapped to both SNOMED CT and ICNP concepts.ConclusionsThese mapping results suggest that physicians' narrative medical records can be structured and can be used for electronic medical record system, and also it is possible for medicine and nursing to share patient care information.

Development and Validation of Detailed Clinical Models for Nursing Problems in Perinatal care.

The aims of this study were to develop detailed clinical models (DCMs) for nursing problems related to perinatal care and to test the applicability of these detailed clinical models. First, we extracted entities of nursing problems by analyzing nursing-problem statements from nursing records, reviewing the literature, and interviewing nurse experts. Second, we extracted attributes and possible values needed to describe the entities in more detail by again analyzing nursing statements, reviewing the literature, and consulting nurse experts. Third, DCMs were modeled by linking each entity with possible attributes with value sets and optionalities. Fourth, entities, attributes and value sets in the DCMs were mapped to the International Classification for Nursing Practice (ICNP) version 2. Finally, DCMs were validated by consulting a group of experts and by applying them to real clinical data and nursing care scenarios published in the literature. The adequacy of the entities, attributes, value sets, and optionalities of the attributes were validated. Fifty-eight entities were identified, 41 entities from nursing records, 12 entities from literature review and 5 entities from nurse experts. Sixty-five attributes with values were identified, 25 attributes from nursing records, 34 attributes from literature review, and 6 attributes from nurse experts. In total 58 DCMs were developed and validated. The DCMs developed in this study can ensure that electronic health records contain meaningful and valid information, and support the semantic interoperability of nursing information.

Representing nursing knowledge on maternal and neonatal health: a study on the cultural suitability of ICNP®

The purpose of this study was to explore the representation of knowledge among nurses and midwives in a maternal and obstetrics setting, in a hospital in northern Portugal. The research had two main objectives: to contribute to the identification and definition of concepts that represent nursing knowledge in obstetrics and to participate in the validation of the International Classification for Nursing Practice (ICNP)®. Using a qualitative approach, the study was designed in three phases. The first phase aimed to identify the terms and expressions used by nurses in nursing documentation and oral report, using document analysis, observation and interview as data collection methods. The second phase intended to determine which terms and expressions corresponded to ICNP® concepts. The third phase aimed to analyse the definition of some ICNP® concepts. In both the second and third phases, a consensus approach was used based on the Delphi Technique. ICNP® concepts were identified from the words and expressions used by nurses and midwives to describe their practice. The results of this study suggested modifications on some ICNP® concept definitions, namely burping, bonding, mother-child attachment, infant sucking, false labour pain, aborting, and uterine contraction; and the inclusion of specific characteristics in others, i.e. uterine expulsion, breast engorgement, colic, and hunger. New ICNP® concepts were also suggested, specifically mother-foetal attachment, uterine contraction after labour, pain after labour and foetal well-being. The study confirmed that ICNP® is an important instrument to identify the concepts needed to describe mother and child needs during the perinatal period.