Validación de los indicadores de la nursing outcomes classification para adultos hospitalizados con riesgo de infección

Este estudio tuvo como objetivo validar los indicadores propuestos por los resultados de enfermeria de la Nursing Outcomes Classification para el diagnostico de Riesgo de Infeccion. La validacion del contenido se realizo de acuerdo con la opinion de 12 enfermeros, procedentes de unidades de cuidados clinicos, quirurgicos e intensivos de un hospital. El analisis se baso en la media aritmetica ponderada de las puntuaciones asignadas por los especialistas para cada indicador evaluado, donde fueron validados aquellos que alcanzaron al menos 0.80. Fueron validados 67 indicadores de un total de 132 propuestos para ocho resultados descritos para el diagnostico de Riesgo de Infeccion, los cuales habian sido validados en un estudio anterior. El proceso de validacion de contenido identifico que la Nursing Outcomes Classification presenta indicadores posibles para evaluar e identificar las mejores practicas. Se cree que este estudio servira como un subsidio para la aplicacion de la Clasificacion de Resultados de Enfermeria en la practica, ensenanza e investigacion.


INTRODUCTION
Nowadays, nurses increasingly need to describe and measure the outcomes of their practice, which determined the creation of classification systems like the Nursing Outcomes Classification (NOC). 1 The NOC complements two other nursing classifications, NANDA International, Inc. (NAN-DA-I), which describes the diagnoses, and the Nursing Intervention Classification (NIC), which describes the interventions.4] In Brazil, a cross-sectional study 5 assessed the NOC indicators for the nursing diagnosis (NDx) Ineffective Breathing Pattern in children with cardiac diseases.In that study, 17 NOC indicators were assessed for this NDx, seven of which revealed statistically significant differences between children with and without the NDx.The indicator breathing difficulty was assessed as the main problem among the groups, which permitted the evaluation of the differences and level of breathing problems among children with and without Ineffective Breathing Pattern. 5 Another Brazilian study 6 aimed to determine the validity of the operational definitions constructed for the NOC indicators that assess the breathing pattern in children with congenital heart disease.Therefore, eight trained nurses assessed 45 one-year-old children with the disease who had been previously diagnosed with Ineffective Breathing Pattern.Two indicators were significant in all statistical analyses: asymmetric thorax expansion and percussion sounds. 6][9][10] The number of these studies remains unsatisfactory though, particularly with regard to the NO.Hence, this factor helps to emphasize the importance of research in the area, with a view to reducing the uncertainties, difficulties and limitations met. 11ot only validation studies about the nursing outcomes of the NOC are scarce, 4 but also the methods to develop them.Various models have been proposed for the validation of ND.Fehring's method is highlighted, which has been widely used in nursing and whose main characteristic relates to the diagnostic content and clinical validations.][14][15] As observed, further advances are needed in studies about the NOC with a view to deeper knowledge and use in practice, as described in a recent study that involved patients with heart failure in home care. 168] The NDx Risk for Infection can be identified as the most frequent in hospitalized patients, as a result of different factors in the hospitalization process, demanding a preventive attitude that should guide the nursing actions in the care plan, taking into account is interface with other diagnoses.Risk for Infection is associated, among others, with the treatmentrelated factors (surgery, presence of invasive lines and medication therapy). 10herefore, this research was developed to enhance the knowledge about the NOC.The objective was to validate the indicators of eight outcomes in this classification, previously validated in an earlier study 10 for the NDx Risk for Infection.] The researchers hope that the results of this validation can help to complement and qualify the use of the computerized NP at the study hospital, besides helping other health institutions and supporting the qualification of nursing care.

METHOD
This is an excerpt from a content validation research of the NOC nursing outcomes, based on Fehring's method [10][11][12] adapted for this research.This type of study essentially involves the systematic examination of the assessed content, with a view to determining whether it covers a representative sample of the domain that is to be measured. 19he research was developed at a university hospital in the South of Brazil.The content of the indicators established by the NOC for the assessment of previously validated outcomes was validated, 10 presented in the chapter about links between NOC and NANDA-I for the NDx Risk for Infection.
Fehring recommends that nurse experts be involved in this study.It is known, however, that there are difficulties to find a sample of professionals who attend to the criteria proposed by the author, who acknowledges the fact and indicates the conditions required by the American Nurses Association Social Policy Statement. 12These include at least a Master's degree, research on the NDx under analysis and papers published about diagnoses.These criteria are hard to find in the Brazilian reality.Therefore, in this study, the criteria were modified to permit the development of the research.
Thus, a group of 12 nurse experts was selected who are active at adult clinical, surgical and intensive care services.The criteria to determine the experts in this study were: participate or having participated in study and qualification activities about the NP for at least four months in the last five years or having academic-scientific production on NP and Nursing Classifications; having at least two years of professional experience as a nurse; working at the research institution for at least one year, using the NP; and having at least one year of experience with surgical, clinical or intensive care patients in the last five years.
Fehring proposes the categorization of the NO indicators as critical, with a weighted arithmetic average of 0.80 or more, and supplementary, when the average ranges between 0.79 and 0.50.][10][11][12] In this study, however, the cut-off point for the NO indicators was set at 0.80, eliminating other categories.The cut-off point selected in this study is justified by the 80% inter-expert agreement level Fehring suggests to categorize the main or critical 12 indicators.The inter-expert agreement level of 80% is intended to enhance the consistency, soundness and applicability of the set of NOC nursing outcomes indicators for use in the computer system.Data were collected through an instrument with 132 indicators, related to eight NOC outcomes that had been validated in an earlier study 10 as critical indicators for the NDx Risk for Infection.These are: Knowledge: infection management; Risk control: infectious process; Wound healing: secondary intention; Wound healing: primary intention; Knowledge: treatment procedure(s); Immune status; Tissue integrity: skin and mucous membranes; and Risk control: sexually transmitted diseases. 10he data collection instrument consisted of a seven-column table for each NO: 1 st column -indicators proposed in the NOC; 2 nd to 6 th columns -five-point Likert scale (1=not important; 2=hardly important; 3=important, 4=very important and 5=extremely important) to measure the importance of each indicator in related to the NO and the NDx Risk for Infection; 7 th column -space for the experts to mark suggestions, criticism or observations.
The data were organized in Microsoft Excel 2007 and analyzed using descriptive statistics based on an adaptation of Fehring's method. 10he weighted arithmetic average of the scores the experts attributed to each indicator was calculated, considering the following: 1=0; 2=0.25; 3=0.50; 4=0.75; 5=1.According to the adaptation for this research, indicators with arithmetic average of 0.80 or higher were validated and the remainder was discarded.
The nurse experts who accepted to participate in the research received a letter with information, a questionnaire about their professional characteristics and the data collection instrument.All the participants terms of free and signed the Informed Consent.Approval for the research was obtained from the Health Ethics Committee at the institution, under number 08-184.

RESULTS
The 12 experts were categorized according to their educational background and professional experience (Table 1).Some of them held more than one degree, with five (41.65%)M.Sc.and seven (58.31%) specialists.
In total, 132 NOC indicators were submitted to the content validation process, related to eight proposed outcomes for the NDx Risk for Infection.Of these, 67 critical indicators were validated.For the outcome Knowledge: infectious control, nine indicators were proposed in the NOC, four of which were validated (44.44%) as criti-cal.As for Knowledge: treatment procedure(s), six (60%) out of 10 indicators were validated (Figure 1).The outcome Wound healing: primary intention has 14 indicators in the NOC, nine of which were validated (64.28%).Wound healing: secondary intention has 18 indicators, 10 (55.55%) of which were validated (Figure 3).For the outcome Immune status, 19 indicators are proposed in the NOC, seven of which (36.84%) were validated as critical.The outcome Tissue integrity: skin and mucous membranes has 21 indicators, six of which were validated (28.57%) as critical (Figure 4).

DISCUSSION
Validation is one of the tools used in the NP and is considered an important step, as it contributes to the development and improvement of knowledge and clinical practice. 19In the content validation, the literature offers a systematic content analysis by nurse experts. 11However, it is difficult to set the criteria to include experts in validation studies as, besides the lack of a consensus in the literature about specific criteria, another barrier is related to the specific education and professional qualification of nurses. 20he cut-off point selected in this research is justified by the 80% inter-expert agreement level Fehring 12 suggests to categorize the critical indicators.In addition, the NOC recommendations to select only outcomes and indicators that are truly relevant in the care context where they will be employed is highlighted. 1or the outcome Knowledge: infectious management, 44.44% of the indicators were validated, possibly because the experts consider that the patient's knowledge about the prevention and identification of signs and symptoms, among other infection-related information, can influence its incidence and limit the development of the infectious process, to the extent that the patients themselves are able to identify the signs and symptoms.
The fact that six (60.0%) of the indicators proposed for the NO Knowledge: treatment procedure(s) were validated discloses the importance the nurses grant to the patient's knowledge about the health treatment.Nevertheless, the question is raised whether this outcome and its indicators are truly appropriate to the ND Risk for Infection.It is appropriate for patients to have knowledge about the infectious process, signs, symptoms and prevention methods, but the NO Knowledge: treatment procedure(s) and its indicators are not closely linked with knowledge about the Risk for Infection.The proposal of the NOC authors is emphasized concerning the exclusive use in practice of NO and indicators that are essential in the context they will be used in, discarding non-critical NO and indicators. 1 This can make the evaluation of the NO more objective and demand less time from the nurses.
Among the indicators for the NO Risk control: infectious process, "practices hand sanitization" was scored 0.97, the highest indicator score in this study.] The hands are the main transmission route of nosocomial infection.Hand washing is the most efficient and economical way to prevent hospital infection, a fact that is known around the world. 21oday, attention to patient safety involving the theme "Hand Washing" has been prioritized, like in the "Global Patient Safety Alliance", an initiative by the World Health Organization (WHO) that has been closed with different countries. 23In 1989, the Brazilian Ministry of Health launched the manual "Hand washing" to standardize this technique in Brazilian health services, providing the health professionals with technical support for the hand washing standards and procedures with a view to the prevention of hospital infections.The Ministry of Health further acknowledged the importance of this practice when it included hand washing recommendations in Decree 2616/98, issued on May 12 th 1998.In 2001, to encourage health professionals' adherence to hand washing, the Brazilian National Health Surveillance Agency (ANVISA) launched the campaign "Hand washing -a small gesture, a great attitude". 21he high percentage (100%) of validated indicators for the NO Risk control: sexually transmitted diseases (STDs) can be justified by its specific nature, as the actions these indicators evaluate are extremely important for the NO.Nevertheless, the evaluation of this NO for surgical, clinical and intensive care patients is questioned, as the indicators of this NO are related to actions the patients perform in their community life and are difficult for the health professionals to evaluate during hospitalization.
The NO Wound healing: primary intention and Wound healing: secondary intention have 32 indicators.Nineteen (59.37%) of these were validated.The experts probably validated such a large number of indicators because they consider the surgical incision an important site for contamination by microorganisms and for the development of hospital infection.
In Brazil, it is estimated that Surgical Site Infection (SSI) takes place in 11% of the surgical procedure.This fact extends the hospitalization, generally by 7 to 10 days, increasing morbidity and mortality rates and care costs. 24In addition, SSI represents a great socioeconomic burden due to the hospital costs, besides a burden for the patients, due to the extended distance from their professional activities and relatives. 24urgical wound infection is a severe complication that interferes in the healing process and can increase the patient's discomfort.The first 24 to 48 hours after the surgery are critical, because the inflammation process starts to destroy bacteria that may have been deposited while the wound was open. 25One aspect that needs to be considered is the surgery's classification concerning the degree of contamination, besides other factors, such as age, presence of chronic conditions, habits, nutritional and metabolic status, which will give an idea of the wound infection risk each patient is exposed to. 25s regards the NO Tissue integrity: skin and mucous membranes, the literature describes that invasive, therapeutic or diagnostic procedures can disseminate infectious agents during their accomplishment or dwelling.Most hospital infections are manifested as complications in severely ill patients, due to the hospitalization and the application of invasive or immunosuppressive procedures the patient received either correct or incorrectly.Therefore, it is important to evaluate indicators for the NO Tissue integrity: skin and mucous membranes, as the skin, for example the surgical site mentioned earlier, serves as the entry door for infections to get established in the individual's organism. 22even indicators were validated (36.84%) for the NO Immune status, which is therefore considered important to assess the Risk for Infection.The patient's immunological status directly reflects the possibility of catching an infection, as confirmed in the literature. 22Most hospital infections are caused by a disequilibrium in the existing relation between the normal human microbiota and the host's defense mechanisms.This can happen due to the patient's own baseline pathology, invasive procedures and alterations in the microbial population, generally induced by antibiotics use.The predominant microorganisms in infections rarely cause infections in other situations, have a low virulent load but, due to their innocuous condition and the host's reduced resistance, the infection process develops. 22

CONCLUSION
This study validated the content of the indicators for eight NOC nursing outcomes previously validated for adult clinical, surgical and intensive care patients with the ND Risk for Infection.Out of 132 indicators for these outcomes, 12 nurse experts validated 67 (50.75%).The indicator "practices hand sanitization", related to the NO Risk control: infectious process, received the highest score (0.97).
The use of the nursing classifications has shown significant advances, not only in the quality of the records, but also in the nursing practices.Studies about the theme have highlighted that the existing connection between the NANDA-I, NIC and NOC classifications have enhanced better patient care practices.It is emphasized that simply establishing the ND is insufficient to see all of the patient's needs.To obtain desired and satisfactory outcomes, it is necessary to relate interventions and establish what outcomes are to be achieved.As a study limitation, the fact is indicated that only the indicators of the ND Risk for Infection were validated.The magnitudes of the scales to evaluate these indicators were not considered in this study.Another limitation relates to the adaptation of Fehring's criteria for the inclusion of nurse experts in the study.
Finally, the main implication of this study for clinical practice is to support the implementation of the NOC, together with the NANDA-I nursing diagnoses and NIC interventions in computer systems, at the teaching hospital where the study was undertaken as well as in other health institutions.Nevertheless, other studies are needed to look for the best way to implement the ND and their respective indicators in computer systems.

Figure 1 -
Figure 1 -Indicators validated as critical for the outcomes Knowledge: infectious control and Knowledge: treatment procedure(s).Porto Alegre-RS, 2011

Figure 2 -NO
Figure 2 -Indicators validated as critical for the outcomes Risk Control: infectious process and Risk control: sexually transmitted diseases.Porto Alegre-RS, 2011

Figure 3 -
Figure 3 -Indicators validated as critical for the outcomes Wound healing: primary intention and Wound healing: secondary intention.Porto Alegre-RS, 2011

Figure 4 -
Figure 4 -Indicators validated as critical for the outcomes Immune status and Tissue integrity: skin and mucous membranes.Porto Alegre-RS, 2011 Almeida MA, Seganfredo DH, Barreto LNM, Lucena AF Based on the above, the researchers suggest the clinical validation of the indicators whose content was validated in this study for the ND Risk for Infection in clinical, surgical and intensive care patients.The clinical validation can help to choose truly relevant indicators in the care context they will be employed in, discarding non-critical indicators for the patients in question.

Table 1 -Characteristics of nurse experts in the sample. Porto Alegre-RS, 2011
* some nurses held more than one academic degree