Standardized Nursing Terminologies Research Articles

Use of Standardized Nursing Terminologies to Capture Social Determinants of Health Data: An Integrative Review.

Addressing social determinants of health in nursing care is important for improving health outcomes and reducing health inequities. Using standardized nursing terminologies to capture this information generates sharable data that can be used to achieve these goals and create new knowledge. The purpose of this integrative review was to examine use of standardized nursing terminologies for collecting social determinants of health data in nursing research and practice. The CINAHL, MEDLINE, and Web of Science databases were searched using the terms "social determinants of health" [and] "nursing" [and] "standardized terminology" or names for each of the 12 American Nurses Association-approved terminologies. Limiters included peer-reviewed and English language. After removal of duplicates, 120 articles were found and screened for relevance and quality using a three-step process. This yielded a final sample of seven articles. Article data were extracted and analyzed for themes. In all articles, retrospective, observational, or secondary analysis research designs were used to analyze previously collected data from large, deidentified datasets or research studies. The Omaha System was the only standardized nursing terminology represented in the sample. All operational definitions of social determinants of health included behavioral items. In most studies, a social determinants of health index score was calculated, and data were analyzed using descriptive statistics and visualization methods. Results reported across the articles were diverse; some themes were identified. This review revealed published literature on this topic is limited. More quality improvement and multisite studies that examine the use of standardized nursing terminologies by nurses to collect and use social determinants of health data are needed.

An example of leveraging AI for documentation: ChatGPT-generated nursing care plan for an older adult with lung cancer.

Our article demonstrates the effectiveness of using a validated framework to create a ChatGPT prompt that generates valid nursing care plan suggestions for one hypothetical older patient with lung cancer. This study describes the methodology for creating ChatGPT prompts that generate consistent care plan suggestions and its application for a lung cancer case scenario. After entering a nursing assessment of the patient's condition into ChatGPT, we asked it to generate care plan suggestions. Subsequently, we assessed the quality of the care plans produced by ChatGPT. While not all the suggested care plan terms (11 out of 16) utilized standardized nursing terminology, the ChatGPT-generated care plan closely matched the gold standard in scope and nature, correctly prioritizing oxygenation and ventilation needs. Using a validated framework prompt to generate nursing care plan suggestions with ChatGPT demonstrates its potential value as a decision support tool for optimizing cancer care documentation.

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

To identify and synthesize evidence regarding the documented relationship between the standardized nursing terminologies and the unfinished nursing care phenomenon. 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. 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. 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. 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.

Development of standardized nursing terminology for the process documentation of patients with chronic kidney disease.

European Nursing care Pathways (ENP) is a professional care language that utilizes software to map care processes and utilize the data for research purposes, process control, and personnel requirement calculations. However, there is a lack of internationally developed terminology systems and subset specifically designed for the nutritional management of CKD. The aim of this study was to create a subset of the standardized nursing terminology for nutrition management in patients with chronic kidney disease (CKD). According to the guidelines for subset development, four research steps were carried out: (i) Translation of version 3.2 of the ENP (chapter on kidney diseases) and understanding of the framework structure and coding rules of the ENP; (ii) Identification of relevant six-dimensional nursing terms; (iii) Creation of a framework for the subset; (iv) Review and validation by experts. A subset for CKD nutritional care was created as part of this project, comprising 630 terms, with 17 causal relationships related to nursing diagnoses, 115 symptoms, 31 causes, 34 goals/outcomes, 420 intervention specifications and 13 resources, including newly developed care terms. All terms within the subset have been created using a six-step maintenance procedure and a clinical standard pathway for nutrition management in the SAPIM mode. This terminology subset can facilitate standardized care reports in CKD nutrition management, which is used to standardize nursing practice, quantify nursing, services, guidance on care decisions, promoting the exchange and use of CKD nutrition data and serve as a reference for the creation of standardized subset of nursing terminology in China.

The Nurse‐Patient Relationship in Nursing Documentation: The Scope and Quality of Interactions and Prevalent Interventions in Inpatient Mental Health Units

Aims. (i) To evaluate the scope and quality of nurse‐patient interactions recorded in the clinical notes of inpatient mental health units and (ii) to identify nursing interventions recorded in the context of the nurse‐patient relationship in the clinical notes of inpatient mental health units. Design. A multimethod approach was use. Methods. Employing a quantitative cross‐sectional design for the first aim, and a qualitative content analysis design of secondary data for the second aim. In total, 1,714 clinical notes were examined from 44 randomly selected patients who were hospitalized in five mental health units over the years 2022‐2023. Results. The patient’s experience of the interaction was present in 69.9% (n = 1,198) of the notes. However, only 12.0% (n = 205) of the notes reached a sufficient standard of quality in terms of describing the nurse‐patient interactions. Specifically, more than half of the notes did not reflect any type of nursing intervention (n = 723; 60.4%). Thirty interventions compatible with the nursing intervention classification were identified, of which more than 70% corresponded to domains in the physiological area. Conclusion. This study shows that the quantity and scope of patients’ clinical notes in mental health units do not sufficiently reflect the interventions performed by nurses, nor the quality or impact of these interventions in the context of the nurse‐patient therapeutic relationship. Implications for the Profession and/or Patient Care. Improving the quality of clinical notes by integrating interventions and their impact can increase the quality of nursing care. Impact. The use of standardized nursing terminologies would contribute to the understanding of the extent and quality of nurse‐patient interactions recorded in clinical notes. Thus, standardized documentation would also help to improve these interactions and their recording, which will facilitate decision‐making. Reporting Method. Findings were reported using COREQ and STROBE guidelines. Patient or Public Contributions. There were no patient or public contributions.

Standardizing nursing data extracted from electronic health records for integration into a statewide clinical data research network

BackgroundCare plans documented by nurses in electronic health records (EHR) are a rich source of data to generate knowledge and measure the impact of nursing care. Unfortunately, there is a lack of integration of these data in clinical data research networks (CDRN) data trusts, due in large part to nursing care being documented with local vocabulary, resulting in non-standardized data. The absence of high-quality nursing care plan data in data trusts limits the investigation of interdisciplinary care aimed at improving patient outcomes. ObjectiveTo map local nursing care plan terms for patients’ problems and goals in the EHR of one large health system to the standardized nursing terminologies (SNTs), NANDA International (NANDA-I), and Nursing Outcomes Classification (NOC). MethodsWe extracted local problems and goals used by nurses to document care plans from two hospitals. After removing duplicates, the terms were independently mapped to NANDA-I and NOC by five mappers. Four nurses who regularly use the local vocabulary validated the mapping. Results83% of local problem terms were mapped to NANDA-I labels and 93% of local goal terms were mapped to NOC labels. The nurses agreed with 95% of the mapping. Local terms not mapped to labels were mapped to the domains or classes of the respective terminologies. ConclusionMapping local vocabularies used by nurses in EHRs to SNTs is a foundational step to making interoperable nursing data available for research and other secondary purposes in large data trusts. This study is the first phase of a larger project building, for the first time, a pipeline to standardize, harmonize, and integrate nursing care plan data from multiple Florida hospitals into the statewide CDRN OneFlorida+ Clinical Research Network data trust.

Validation of Nursing Outcomes Classification: Knowledge and Self-management for Cardiac Disease.

The Nursing Outcomes Classification provides two outcomes, Knowledge: Cardiac Disease and Self-management: Cardiac Disease, to assess knowledge and self-management behaviors of adults with cardiac disease. The purpose of this study was to validate the two nursing-sensitive outcomes to establish content validity. A methodological design was used using the Delphi technique. A total of 13 nurse experts in two domains participated in this study: five in standardized nursing terminologies and eight in self-management. Descriptive statistics and the Nurse-Patient Outcome Content Validity method were used to validate four aspects: definition adequacy of each outcome, clinical usefulness of measurement scales, importance of outcome indicators, and content similarity between the two outcomes. The definition adequacy, clinical usefulness, and content similarity of both outcomes were acceptable. A total of 81 indicators from the two outcomes were validated, and 60 were designated as critical. Nurses can evaluate cardiac patient outcomes effectively and accurately using these validated outcomes. The validated Nursing Outcomes Classification outcomes will also support the clinical decision-making of nursing students when they learn about patients with cardiac disease.

Future advancement of health care through standardized nursing terminologies: reflections from a Friends of the National Library of Medicine workshop honoring Virginia K. Saba.

To honor the legacy of nursing informatics pioneer and visionary, Dr. Virginia Saba, the Friends of the National Library of Medicine convened a group of international experts to reflect on Dr. Saba's contributions to nursing standardized nursing terminologies. Experts led a day-and-a-half virtual update on nursing's sustained and rigorous efforts to develop and use valid, reliable, and computable standardized nursing terminologies over the past 5 decades. Over the course of the workshop, policymakers, industry leaders, and scholars discussed the successful use of standardized nursing terminologies, the potential for expanded use of these vetted tools to advance healthcare, and future needs and opportunities. In this article, we elaborate on this vision and key recommendations for continued and expanded adoption and use of standardized nursing terminologies across settings and systems with the goal of generating new knowledge that improves health. Much of the promise that the original creators of standardized nursing terminologies envisioned has been achieved. Secondary analysis of clinical data using these terminologies has repeatedly demonstrated the value of nursing and nursing's data. With increased and widespread adoption, these achievements can be replicated across settings and systems.

Utilizing standardized nursing terminologies in implementing an AI-powered fall-prevention tool to improve patient outcomes: a multihospital study.

Standardized nursing terminologies (SNTs) are necessary to ensure consistent knowledge expression and compare the effectiveness of nursing practice across settings. This study investigated whether SNTs can support semantic interoperability and outcoming tracking over time by implementing an AI-powered CDS tool for fall prevention across multiple EMR systems. The study involved 3 tertiary academic hospitals and 1 public hospital with different EMR systems and nursing terms, and employed an AI-powered CDS tool that determines the fall risk within the next hour (prediction model) and recommends tailored care plans (CDS functions; represented by SNTs). The prediction model was mapped to local data elements and optimized using local data sets. The local nursing statements in CDS functions were mapped using an ICNP-based inpatient fall-prevention catalog. Four implementation models were compared, and patient outcomes and nursing activities were observed longitudinally at one site. The postimplementation approach was practical for disseminating the AI-powered CDS tool for nursing. The 4 hospitals successfully implemented prediction models with little performance variation; the AUROCs were 0.8051-0.9581. The nursing process data contributed markedly to fall-risk predictions. The local nursing statements on preventing falls covered 48.0%-86.7% of statements. There was no significant longitudinal decrease in the fall rate (P = .160, 95% CI = -1.21 to 0.21 per 1000 hospital days), but rates of interventions provided by nurses were notably increased. SNTs contributed to achieving semantic interoperability among multiple EMR systems to disseminate AI-powered CDS tools and automatically track nursing and patient outcomes.

FHIR-up! Advancing knowledge from clinical data through application of standardized nursing terminologies within HL7® FHIR®.

Health Level 7®'s (HL7) Fast Healthcare Interoperability Resources® (FHIR®) is leading new efforts to make data available to healthcare clinicians, administrators, and leaders. Standardized nursing terminologies were developed to enable nursing's voice and perspective to be visible within the healthcare data ecosystem. The use of these SNTs has been shown to improve care quality and outcomes, and to provide data for knowledge discovery. The role of SNTs in describing assessments and interventions and measuring outcomes is unique in health care, and synergistic with the purpose and goals of FHIR. FHIR acknowledges nursing as a discipline of interest and yet the use of SNTs within the FHIR ecosystem is rare. The purpose of this article is to describe FHIR, SNTs, and the potential for synergy in the use of SNTs with FHIR. Toward improving understanding how FHIR works to transport and store knowledge and how SNTs work to convey meaning, we provide a framework and examples of SNTs and their coding for use within FHIR solutions. Finally, we offer recommendations for the next steps to advance FHIR-SNT collaboration. Such collaboration will advance both nursing specifically and health care in general, and most importantly, improve population health.

Uncovering hidden trends: identifying time trajectories in risk factors documented in clinical notes and predicting hospitalizations and emergency department visits during home health care.

This study aimed to identify temporal risk factor patterns documented in home health care (HHC) clinical notes and examine their association with hospitalizations or emergency department (ED) visits. Data for 73350 episodes of care from one large HHC organization were analyzed using dynamic time warping and hierarchical clustering analysis to identify the temporal patterns of risk factors documented in clinical notes. The Omaha System nursing terminology represented risk factors. First, clinical characteristics were compared between clusters. Next, multivariate logistic regression was used to examine the association between clusters and risk for hospitalizations or ED visits. Omaha System domains corresponding to risk factors were analyzed and described in each cluster. Six temporal clusters emerged, showing different patterns in how risk factors were documented over time. Patients with a steep increase in documented risk factors over time had a 3 times higher likelihood of hospitalization or ED visit than patients with no documented risk factors. Most risk factors belonged to the physiological domain, and only a few were in the environmental domain. An analysis of risk factor trajectories reflects a patient's evolving health status during a HHC episode. Using standardized nursing terminology, this study provided new insights into the complex temporal dynamics of HHC, which may lead to improved patient outcomes through better treatment and management plans. Incorporating temporal patterns in documented risk factors and their clusters into early warning systems may activate interventions to prevent hospitalizations or ED visits in HHC.

Comparison of SIREN social needs screening tools and Simplified Omaha System Terms: informing an informatics approach to social determinants of health assessments.

Numerous studies indicate that the social determinants of health (SDOH), conditions in which people work, play, and learn, account for 30%-55% of health outcomes. Many healthcare and social service organizations seek ways to collect, integrate, and address the SDOH. Informatics solutions such as standardized nursing terminologies may facilitate such goals. In this study, we compared one standardized nursing terminology, the Omaha System, in its consumer-facing form, Simplified Omaha System Terms (SOST), to social needs screening tools identified by the Social Interventions Research and Evaluation Network (SIREN). Using standard mapping techniques, we mapped 286 items from 15 SDOH screening tools to 335 SOST challenges. The SOST assessment includes 42 concepts across 4 domains. We analyzed the mapping using descriptive statistics and data visualization techniques. Of the 286 social needs screening tools items, 282 (98.7%) mapped 429 times to 102 (30.7%) of the 335 SOST challenges from 26 concepts in all domains, most frequently from Income, Home, and Abuse. No single SIREN tool assessed all SDOH items. The 4 items not mapped were related to financial abuse and perceived quality of life. SOST taxonomically and comprehensively collects SDOH data compared to SIREN tools. This demonstrates the importance of implementing standardized terminologies to reduce ambiguity and ensure the shared meaning of data. SOST could be used in clinical informatics solutions for interoperability and health information exchange, including SDOH. Further research is needed to examine consumer perspectives regarding SOST assessment compared to other social needs screening tools.

Impact of standardized nursing terminologies on patient and organizational outcomes: A systematic review and meta-analysis.

To explore the impact of 12 American Nurses Association recognized standardized nursing terminologies (SNTs) on patient and organizational outcomes. Previous studies reported an effect of SNTs on outcomes, but no previous frameworks nor meta-analyses were found. Systematic review and meta-analyses. PubMed, Scopus, CINAHL, and OpenGrey databases were last consulted in July 2021. All abstracts and full texts were screened independently by two researchers. The review included primary quantitative studies that reported an association between recognized SNTs and outcomes. Two reviewers independently assessed the risk of bias and certainty of evidence for each meta-analyzed outcome using the "Grading of Recommendations, Assessment, Development and Evaluation" (GRADE) approach. Fifty-three reports were included. NANDA-NIC-NOC and Omaha System were the most frequently reported SNTs used in the studies. Risk of bias in randomized controlled trials and not-randomized controlled trials ranged from high to unclear, this risk was low in cross-sectional studies. The number of nursing diagnoses NANDA-I moderately correlated with the intensive care unit length of stay (r=0.38; 95% CI=0.31-0.44). Using the Omaha System nurse-led transitional care program showed a large increase in both knowledge (d=1.21; 95% CI=0.97-1.44) and self-efficacy (d=1.23; 95% CI=0.97-1.48), while a reduction on the readmission rate (OR=0.46; 95% CI=0.09-0.83). Nursing diagnoses were found to be useful predictors for organizational (length of stay) and patients' outcomes (mortality, quality of life). The GRADE indicated that the certainty of evidence was rated from very low to low. Studies using SNTs demonstrated significant improvement and prediction power in several patients' and organizational outcomes. Further high-quality research is required to increase the certainty of evidence of these relationships. SNTs should be considered by healthcare policymakers to improve nursing care and as essential reporting data about patient's nursing complexity to guide reimbursement criteria.

Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health Data.

In electronic health records (EHRs), standardized nursing terminologies (SNTs), such as nursing diagnoses (NDs), are needed to demonstrate the impact of nursing care on patient outcomes. Unfortunately, the use of NDs is not common in clinical practice, especially in surgical settings, and is rarely included in EHRs. The aim of the study was to describe the prevalence and trend of NDs in a hospital surgical setting by also analyzing the relationship between NDs and hospital outcomes. A retrospective study was conducted. All adult inpatients consecutively admitted to one of the 15 surgical inpatient units of an Italian university hospital across 1 year were included. Data, including the Professional Assessment Instrument and the Hospital Discharge Register, were collected retrospectively from the hospital's EHRs. The sample included 5,027 surgical inpatients. There was a mean of 6.3 ± 4.3 NDs per patient. The average distribution of NDs showed a stable trend throughout the year. The most representative NANDA-I ND domain was safety/protection. The total number of NDs on admission was significantly higher for patient whose length of stay was longer. A statistically significant correlation was observed between the number of NDs on admission and the number of intra-hospital patient transfers. Additionally, the mean number of NDs on admission was higher for patients who were later transferred to an intensive care unit compared to those who were not transferred. NDs represent the key to understanding the contribution of nurses in the surgical setting. NDs collected upon admission can represent a prognostic factor related to the hospital's key outcomes.

Urinary incontinence in women: assessment with the aid of standardized nursing terminologies NANDA-I and NOC.

to assess urinary impairment in incontinent women with the aid of standardized nursing terminologies NANDA-I and NOC. a cross-sectional study, carried out with 97 women attending the gynecology outpatient clinic of a university hospital. Data collection took place using a form that contained information about NANDA-I diagnoses related to urinary incontinence and NOC Urinary Continence indicators. Statistical analysis was performed to assess the impairment of NOC indicators in the presence of NANDA-I nursing diagnoses. diagnosis Mixed Urinary Incontinence was the most prevalent (43.3%), and, in its presence, the most compromised indicators were voids in appropriate receptacle, gets to toilet between urge and passage of urine and empties bladder completely. urinary impairment was worse in women with elements of stress and urge urinary incontinence.

Urinary incontinence in women: assessment with the aid of standardized nursing terminologies NANDA-I and NOC

RESUMO Objetivos: avaliar o comprometimento urinário em mulheres incontinentes com o auxílio das terminologias padronizadas em enfermagem NANDA-I e NOC. Métodos: estudo transversal, realizado com 97 mulheres em atendimento no ambulatório de ginecologia de um hospital universitário. A coleta de dados ocorreu por meio de formulário que continha informações sobre diagnósticos da NANDA-I relacionados à incontinência urinária e indicadores do resultado NOC Continência Urinária. Foi realizada análise estatística para avaliar o comprometimento dos indicadores da NOC na presença dos diagnósticos de enfermagem da NANDA-I. Resultados: o diagnóstico Incontinência Urinária Mista foi o mais prevalente (43,3%), e, na sua presença, os indicadores mais comprometidos foram urina em recipiente apropriado, chega ao banheiro entre o desejo e a passagem de urina e esvazia a bexiga completamente. Conclusões: o comprometimento urinário demonstrou-se pior nas mulheres com elementos de incontinência urinária de esforço e urgência.

Epidermolysis Bullosa: A case study in Cyprus and the nursing care plan.

To present a case study with Epidermolysis bullosa (EB) in Cyprus and to determine the nursing care plan, explaining the nursing interventions and showing the importance of nursing care of patients with EB. Literature review on EB and semi-structured interviews commenced through a direct discussion with open-ended questions to the research subject as well as to a close relative describing his feelings, experiences, and concerns about the disease. Thematic analysis approach was used to identify and analyze patterns in the data. Then, data were synthesized using the standardized nursing terminology of NANDA-I and the Nursing Interventions Classification. The accuracy of the diagnoses and the appropriateness of the nursing interventions were supported by the positive health outcomes of the patient. Nurses should apply evidence-based practice interventions for EB wound care, pain management, nutrition, psychological and social support to these patients. Although EB is classified in the category of rare diseases, the presentation of a case study in Cyprus and the nursing care plan contribute further bibliographically to the holistic and at the same time individualized nursing practice.

Detecting Language Associated With Home Healthcare Patient's Risk for Hospitalization and Emergency Department Visit.

About one in five patients receiving home healthcare (HHC) services are hospitalized or visit an emergency department (ED) during a home care episode. Early identification of at-risk patients can prevent these negative outcomes. However, risk indicators, including language in clinical notes that indicate a concern about a patient, are often hidden in narrative documentation throughout their HHC episode. The aim of the study was to develop an automated natural language processing (NLP) algorithm to identify concerning language indicative of HHC patients' risk of hospitalizations or ED visits. This study used the Omaha System-a standardized nursing terminology that describes problems/signs/symptoms that can occur in the community setting. First, five HHC experts iteratively reviewed the Omaha System and identified concerning concepts indicative of HHC patients' risk of hospitalizations or ED visits. Next, we developed and tested an NLP algorithm to identify these concerning concepts in HHC clinical notes automatically. The resulting NLP algorithm was applied on a large subset of narrative notes (2.3 million notes) documented for 66,317 unique patients ( n = 87,966 HHC episodes) admitted to one large HHC agency in the Northeast United States between 2015 and 2017. A total of 160 Omaha System signs/symptoms were identified as concerning concepts for hospitalizations or ED visits in HHC. These signs/symptoms belong to 31 of the 42 available Omaha System problems. Overall, the NLP algorithm showed good performance in identifying concerning concepts in clinical notes. More than 18% of clinical notes were detected as having at least one concerning concept, and more than 90% of HHC episodes included at least one Omaha System problem. The most frequently documented concerning concepts were pain, followed by issues related to neuromusculoskeletal function, circulation, mental health, and communicable/infectious conditions. Our findings suggest that concerning problems or symptoms that could increase the risk of hospitalization or ED visit were frequently documented in narrative clinical notes. NLP can automatically extract information from narrative clinical notes to improve our understanding of care needs in HHC. Next steps are to evaluate which concerning concepts identified in clinical notes predict hospitalization or ED visit.

Health IT advances for the 21st century.

The United States is working toward a value-based health care system in which reimbursement will be based on quality outcomes rather than on Current Procedural Terminology payment codes. Health data will be more easily shared, and patients will have more control of their records. Health information technology advances in the federal 21st Century Cures Act follow earlier related legislation and regulation that moved clinical care and research forward. Policy analysis of the Cures Act is presented following the three phases of the Longest model (2010): formation, implementation, and modification. With the passage of the Cures Act and promulgation of its final rules, the formation phase is complete. The implementation phase has begun. Modification may occur, based on the evaluation of key deliverables over time. Advanced practice nurses are well-suited to the use of electronic tools to share data with patients and other providers. New competencies, tools, and infrastructure are needed for advanced practice nurses to fully participate in value-based health care. Full implementation of the 21st Century Cures Act with the use of coded concepts in standardized nursing terminologies will provide an ideal foundation for strong patient-centered care, population health, and reimbursement that takes advanced nursing practice into account.

Filling a gap in standardized nursing terminology. Development of a new nursing diagnosis proposal on heart failure self-care.

Heart failure is a highly prevalent chronic health problem associated with poor quality-of-life and negative outcomes. Self-care is a cornerstone in patients suffering from heart failure. Nurses are commonly engaged in enhancing patients' self-care behaviors, but the specific condition of deficit on self-care is not clearly identified by nurses. No nursing diagnoses focused on self-care of heart failure patients is currently available. This study aimed to develop a new nursing diagnosis that focuses on self-care in heart failure patients. A concept and content analysis were used. Some steps of the concept analysis were performed through an integrative literature review conducted searching in PUBMED and CINAHL databases to identify attributes, antecedents, and consequences of the diagnosis. Forty-five articles were selected from the 1450 studies found. Then, the content analysis was performed by an international panel of 29 experts. Two Delphi rounds were used to achieve consensus and an item content validity index was calculated for each diagnostic element. Integrative review proposed four diagnostic labels, two definitions, 15 defining characteristics, and 44 related factors. After the two Delphi rounds a consensus was reached for each diagnostic indicator with a content validity index ranging from 82.8% to 100%. The nursing diagnosis-labeled heart failure self-care deficit-was validated with a definition, eight defining characteristics, 15 related factors, and five at-risk populations. This diagnosis allows nurses to document patients' self-care in daily clinical practice through a standard nursing terminology, by naming this health problem, describing its etiology, and clinical manifestations. This new diagnosis is expected to assist nursing clinicians, educators, and students in clinical reasoning with the aim to improve diagnostic accuracy in identifying patients with a heart failure self-care deficit, to select the most appropriate interventions and pursue better outcomes.