Ineffective health management in hemodialysis patients : content analysis

Objective: To analyze the content of the nursing diagnosis Ineffective Health Management in hemodialysis patients. Method: The Nursing Diagnoses Validation Model by Lopes, Silva and Auraújo was used in this research. A semi-structured questionnaire and evaluated the defi nition, location, defi ning characteristics, and related factors of the diagnosis Ineffective Health Management was answered by 22 experts in nursing diagnosis. The analysis was conducted from August 2014 to January 2015. Results: Experts considered the proposed defi nition and the current location in the taxonomy II by the NANDA-I, Domain 1 Health Promotion, Class 2 Health Control, adequate to the diagnosis. The adequacy level adopted at 85% or p > 0.05 were above 10 defi ning characteristics and 24 related factors. Experts also suggested that one defi ning characteristic should become a related factor and that three factors should turn into defi ning characteristics. Conclusion: A new proposal was developed for the diagnosis under study after the analysis of experts. Descriptors: Validation Studies; Nursing Diagnosis; Renal Dialysis; Taxonomy; Nursing. RESUMO Objetivo: Analisar o conteúdo do diagnóstico de enfermagem Autocontrole inefi caz da saúde em pacientes em hemodiálise. Método: O Modelo de Validação de Diagnóstico de Enfermagem por Lopes, Silva e Araújo foi usado nesta pesquisa. Um questionário semiestruturado foi respondido por 22 especialistas em diagnóstico de enfermagem e, avaliou a defi nição, localização, características defi nidoras e fatores relacionados do diagnóstico Autocontrole inefi caz da Saúde. A análise foi realizada de agosto de 2014 a janeiro de 2015. Resultados: Os especialistas consideraram como adequada ao diagnóstico, a defi nição proposta e a localização atual na taxonomia II da NANDA-I, promoção de saúde do domínio 1, controle de saúde na classe 2. O nível de adequação adotado foi superior a 85% ou p> 0,05 para 10 características defi nidoras e 24 fatores relacionados. Especialistas também sugeriram que uma característica defi nidora deveria se tornar um fator relacionado e que três fatores devem se transformar em características defi nidoras. Conclusão: Uma nova proposta foi desenvolvida para o diagnóstico em estudo após a análise de especialistas. Descritores: Estudos de validação; Diagnóstico de Enfermagem; Diálise Renal; Taxonomia; Enfermagem. RESUMEN Objectivo: Analizar el contenido del diagnóstico de enfermería Mantenimiento Inefi caz de la Salud en pacientes en hemodiálisis. Método: El modelo de validación de diagnóstico de enfermería de Lopes, Silva y Auraújo fue utilizado en esta investigación. Un cuestionario semiestructurado que evaluó la defi nición, ubicación, características defi nitorias y factores relacionados con el diagnóstico Mantenimiento Inefi caz de la Salud fue respondido por 22 expertos en diagnóstico de enfermería. El análisis se realizó entre agosto de 2014 y enero de 2015. Resultados: Los expertos consideraron la defi nición propuesta y la ubicación Ineffective health management in hemodialysis patients: content analysis Autocontrole inefi caz da saúde em pacientes em hemodiálise: análise de conteúdo Mantenimiento inefi caz de la salud en pacientes en hemodiálisis: análisis de contenido


INTRODUCTION
The validation of a nursing diagnosis (ND) has three stages, namely: concept analysis, content analysis by experts, and accuracy of clinical indicators (1) .Assessment conducted by experts in ND contributes to make decision-making more reliable, accurate, and positive in nursing care (2) .
The clientele undergoing hemodialysis experiences frequent changes Which require require significant control in everyday life.Patients are subject to water and food restriction, strict drug therapy and continuous hemodialysis.Thus, the difficulty to adhere to treatment becomes more apparent in this population, giving rise to negative feelings related to limitations imposed by disease, and affecting well-being at the biopsychosocial level (3) .The ND in the NANDA-I that is most suited to individuals who do not effectively adhere to therapy is Ineffective Health Management (00078).
This ND belongs to the domain health promotion, in the health management class, and is defined as "pattern of regulating and integrating into daily living a therapeutic regimen for the treatment of illness and its after-effect that are unsatisfactory for meeting specific health goals" (4) .
A previous study conducted a conceptual analysis of the ND Ineffective Health Management in patients undergoing hemodialysis proposed to redefine this ND as "patient's inability to control habits and achieve therapeutic targets agreed with professionals, resulting in health complications" (5) .Identified related factors were: poor knowledge; inadequate use of medications; non-adherence to water restriction; chronic sadness; sociodemographic factors; deficient social support network; non-adherence to treatment; beliefs; economic difficulties; lack of motivation; negative psychological state; miscommunication; non-adherence to food restriction; treatment complexity; anxiety; comorbidities; self-efficacy; lack of emotional support; lack of fistula care/vascular access; maladjustment to new conditions; irregular attendance to dialysis sessions; lack of transport to attend dialysis sessions; treatment dropout; negative self-image; health policy; neurocognitive dysfunction; negotiation failure; inadequate dialysis; ill-defined treatment plan; asymptomatic nature of disease; fistula puncture pain; identification of barriers to change; and lack of planning.
The defining characteristics proposed (5) were: high interdialytic weight gain; quality of life; longer length of hospitalization; severe complications of kidney disease; low self-esteem; changes in laboratory tests; fatigue; increased symptoms; lack of treatment; change in treatment time; emergency care; infection; increased cost of treatment; fistula issues; difficult fluid removal during hemodialysis; and treatment dropout.However, content analysis was not validated.
Studies identified ND in hemodialysis patients and Ineffective Health Management were rated in different frequencies by the authors (6)(7)(8) .Such difference may indicate the need to further analyze ND, providing components that best characterize the ND in specific patients.Therefore, content analysis by experts should be conducted after concept analysis, and it is important for the understanding of diagnosis in the context it is inserted.
Therefore, validation studies contribute to diagnostic accuracy, planning of appropriate interventions, positive health outcomes for the individual, family, community, and brings important contribution to nursing as a science.
Given these factors, the guiding question of this research was: "Are the components of the Nursing Diagnosis Ineffective Health Management detected in the hemodialysis clientele?"Thus, this study consists in a content analysis of the ND Ineffective Health Management in hemodialysis patients.
From this perspective, the process aims to favor the identification of ND components (definition, defining characteristics, related factors, and empirical definitions) in order to meet the actual individual needs and to provide faster identification of nursing issues, proposing consistent, safe, and effective goals, contributes to systematize a problem-solving nursing care.

OBJECTIVE
To analyze the content of the nursing diagnosis Ineffective Health Management in hemodialysis patients.

METHOD Ethical aspects
Study approved by the Research Ethics Committee of the Federal University of Rio Grande do Norte (UFRN) and the Certificate of Submission for Ethical Assessment (CSEA), complying with the Resolution 466/2012 of the Brazilian National Health Council (CNS) (9) .

Designs
Content analysis conducted by experts in ND, based on the second stage proposed in the Nursing Diagnoses Validation Model (1) , tested the adequacy of components proposed to the ND Ineffective Health Management (5) .

Analysis of results
All data was processed using the software Microsoft Excel®, 2010 version.The analysis was performed using the Statistical Package for the Social Sciences® (SPSS), 16.0 version, resorting to a binomial test to determine the proportion of experts who indicate that each adequate item was not below 85%.For that, the significance level adopted was 5%, with p > 0.05, and the adequate item was above 85%.Consequently, the components that did not show these proportions were excluded from the final proposal of the ND Ineffective Health Management.

RESULTS
The 22 experts selected to evaluate the ND Ineffective Health Management are characterized in Table 1.
In 2016, 91% of the participants worked in educational institutions and 86.4% taught ND, 63.3% reported to provide care to hemodialysis patients or those with the ND Ineffective Health Management, and 45.5% reported practical identification of this ND in few cases.
the expected percentage of experts indicating the suitability of each item (85%); and "e" represents the acceptable proportional difference from the results expected (15%) (1) .

Inclusion and exclusion criteria
Experts were selected based on the Brazilian National Council of Technological and Scientific Development (CNPq) Lattes Platform.Expert inclusion criteria were to be clinically experienced in hemodialysis; and have published studies on nursing diagnoses.All experts with this profile were selected.

Study protocol
The analysis was conducted from August 2014 to January 2015.Initially, the number of experts selected was above the sampling calculation, due to the possibility of failure to make contact, refusal to participate, and incomplete information.Therefore, an invitation letter was sent by email to 37 experts selected according to the inclusion criteria.The result was, 3 (8.1%)did not accept to participate in the study and 12 (32.4%)did not send complete information (after 3 attempts), totaling 22 experts (59.5%).
After acceptance to participate in the research, each expert received, via email, a free and informed consent term, with general information about the study.This document was then signed, scanned, and sent back to the researcher.Next, a data collection instrument was sent to each participant expert.
The instrument consisted of a two-part semistructured questionnaire: the first on identification data and expert experience, and the second on validation of the ND Ineffective Health Management (definition, location, defining characteristics, and related factors).Experts were asked to rate on a five-level Likert scale: 1) no indicative/relevant; 2) very little indicative/ relevant; 3) somewhat indicative/relevant; 4) very indicative/relevant; and 5) extremely indicative/ relevant.The items classified as 1, 2, or 3 were grouped as inadequate and the items classified into 4 or 5 were grouped as adequate, recording the data as dichotomous.Regarding the definition of the ND Ineffective Health Management, the experts were informed about the current taxonomy II by the NANDA-I, having the concept analysis by Silva (2013) as a basis; 54.5% of the experts claimed that the author provided the most appropriate definition for this ND: "Patient's inability to control habits and achieve the therapeutic goals agreed with professionals, resulting in health complications" (5).
As for the location of the ND Ineffective Health Management, two positions were pointed out: Domain 1: Health Promotion and Class 2: Health Control, current location of the ND in the taxonomy II by the NANDA-I; and Domain 1: Health Promotion and Class 1: Health Perception, addressed by the concept analysis.In this case, 100% of the experts regarded the current location of this ND as adequate.
The 22 experts evaluated the clinical indicators of the ND Ineffective Health Management in the taxonomy II by the NANDA-I (Table 2).
The defining characteristics below the adequacy level adopted (85% or p>0.05) were removed from the ND Ineffective Health Management; thus, 11 clinical indicators of this ND were excluded from the concept analysis.
Regarding the title of defining characteristics, some experts also suggested changes, namely: "Intensified complications of chronic kidney disease" becomes "Intensified complications of disease;" "Quality of life" becomes "Impaired quality of life;" "Increased effects of symptoms" becomes "Intensified symptoms of disease;" "Seeking emergency services" becomes "Often seeking hospital services;" and "Expressed wish to control the disease" becomes "Non-expressed wish to control the disease."It was suggested that "Often seeking hospital services" was assigned to factors related to the ND under study.The suggestions were regarded as pertinent, therefore, accepted.
The 22 experts evaluated the adequacy of factors related to the ND under study (Table 3).
The related factors that showed a concordance index below 85% or p<0.05 were excluded.Thus, there were 22 related factors taken from the ND Ineffective Health Management.
The experts were asked about the most appropriate nomenclature for two related factors found in the concept analysis that were similar to those provided by the NANDA-I: "Poor knowledge" vs. "Knowledge deficit" and "Identification of barriers to changes" x "Perceived barriers."Therefore, 72.7% of the experts considered the term "Poor knowledge" as the most appropriate and 54.5% considered "Perceived barriers" as the most pertinent.The experts suggested to change the terminological level of related factors: "Sociodemographic factor" becomes "Unfavorable sociodemographic factor;" "Inappropriate use of medications" becomes "Inappropriate use of drugs;" "Negative self-image" becomes "Negative body image;" "Previous experiences" becomes "Negative previous experiences;" "Perceived benefits" becomes "Nonperceived benefits;" "Perceived severity" becomes "Non-perceived disease severity."They also suggested to turn "Inappropriate use of medications," "Non-adherence to treatment," and "Irregular attendance to hemodialysis sessions" into defining characteristics.The suggestions were regarded as pertinent, therefore, accepted.
Chart 1, displays the final proposal for the ND Ineffective Health Management, having the findings of this study as a basis.

Content analysis of the ND Ineffective
Health Management with regard to hemodialysis patients contributes to improve nursing care, by providing professionals with a refined taxonomy, making this ND more reliable.
The experts evaluated the adequacy of the ND clinical indicators having knowledge acquired through professional, clinical, or academic experience as a basis.The characterization of study participants is similar to other studies conducted to validate nursing classifications (5,(10)(11)(12) .It is worth noticing that experts were selected considering their academic titles, studies, and clinical experience with the theme addressed (13) .
The definition of a ND must be clear and concise, in order to make decisionmaking and communication easier in the nursing team (4) .Therefore, the experts chose the definition proposed having concept analysis as a basis.In terms of location, the experts chose the Domain 1: Health Promotion and Class 2: Health Control.The domain Health Promotion is defined as "perception of well-being or normal function and strategies used to keep control of this well-being and normal function, as well as to improve them," and the class Health Control consists in "identification, control, performance, and interconnection of activities to maintain health and well-being" (4) .
To establish effective health control, hemodialysis patients have to adhere to treatment.It is known that this clientele tend to comply with treatment, which is decisive for survival, but not as a comprehensive practice, due to several factors, such as: waking up early; distance between the household and the clinic; transport issues; frequency and time devoted to hemodialysis; pain or discomfort in arteriovenous fistula puncture; arteriovenous fistula care; financial, psychological, nutritional, and cultural factors; complex therapy; water restriction; dependency on caregivers; poor knowledge; social role; and educational level (14)(15) .It is essemtial that individuals undergoing hemodialysis adapt to a new lifestyle.Their chances of survival include water and food restrictions, drug therapy, limited ability to fulfill daily life activities, in addition to getting connected to a machine during the hemodialysis session, over four hours, three times a week.
Furthemore, catheter or arteriovenous fistula are used, the patients are connected to a machine and their body  changes, making her/him insecure and fearful regarding body image (16) .This often gives rise to emotional issues that culminate in low self-esteem, anxiety, and depression in this clientele (17)(18) .Moreover, poor knowledge on self-care is an intrinsic factor for non-adherence to treatment and ineffective health care (19)(20) .Chronic kidney disease derives from metabolic complications and comorbidities, resulting in multiple use of drugs (21) .
A study reveals that when the patient accepts the treatment, complying with diet and medication prescriptions, lower is the chance of complications related to disease and treatment (22) .In addition to knowledge and discipline, hemodialysis patients need to be supported by family members and friends, as well as the health team.The support network has a positive impact on the hemodialysis clientele (23)(24) .
From this perspective, content analysis of the ND Ineffective Health Management provides significant knowledge for nursing professionals, which enabling them to identify the indicators with greater accuracy and clarity and facilitates decision-making and communication in the nursing team.

Study limitations
Methodological limitations of this research consist in the extension of the instrument's items, and slowness of responses.Therefore, it is worth mentioning the possibility of more objective instruments and other methodological approaches to be used with these experts.Another limitation is related to the study design, since only experts on the Lattes Platform were selected and there was a single round to collect the data.For that rreason, other methodological approaches could be used with these experts, such as the Delphi method.

Contributions to nursing
We hope that the findings of this study contribute to the clinical validation of the ND concerned.

CONCLUSION
The final proposal for the ND Ineffective Health Management, having content analysis by experts as basis, considered adequate the proposed definition and the current location in the taxonomy II by the NANDA-I, Domain 1 (Health Promotion), Class 2 (Health Control).
The proposed definition for nursing diagnosis of Ineffective Health Management, based on the opinion of experts was: Patient's inability to control habits and achieve therapeutic goals agreed with professionals, resulting in health complications.
The experts regard 12 defining characteristics as adequate, namely: Expressed difficulty with prescribed regimens; Daily life choices ineffective to achieve health goals; Intensified complications of disease; Changes in laboratory tests; Intensified symptoms of disease; High interdialytic weight gain (over 2 kg); Infection; Non-expressed wish to control the disease; Impaired quality of life; Irregular attendance to hemodialysis sessions; Non-adherence to treatment; And Inappropriate use of drugs.
The adequacy of 22 related factor is indicated, they are: Complexity of the therapeutic regimen; Poor knowledge; Failure to communicate; Failure to adapt to new conditions; Lack of motivation; Lack of planning; Lack of emotional support; Asymptomatic nature of disease; Time spent on hemodialysis sessions; Comorbidities; Withdrawal from goals; Neurocognitive dysfunction; Non-perceived disease severity; Negative body image; Beliefs; Negative previous experiences; Unfavorable sociodemographic factor; Chronic sadness; Anxiety; Non-perceived benefits; Residual kidney function; And Often seeking hospital services.
The results of this study can contribute to the adequate application of the ND Ineffective Health Management and support clinical validation studies.It also brings important contribution to nursing as a science.
Hence, clinical validation is recommended to identify the accuracy of the defining characteristics and contribute to the diagnosis judgment of the nurse, in order to address more clearly the care provided to patients.

Table 2 -
Adequacy of the clinical indicators of the nursing diagnosis Ineffective Health Management Note: * Binomial test.