Conceptual validation of the defining characteristics of respiratory nursing diagnoses in neonates

Abstracts

OBJECTIVE:

To develop and validate conceptual and operational definitions for the defining characteristics of the respiratory nursing diagnoses, ineffective breathing pattern, impaired gas exchange and impaired spontaneous ventilation, in newborns.

METHODS:

This was a methodological study of conceptual validation of the defining characteristics of three respiratory nursing diagnoses, by consensus analysis of a committee of five specialist nurses, and then a group of five non-nursing professionals, using the Delphi technique.

RESULTS:

After two rounds of evaluation, consensus was obtained that was equal to or greater than 80% on all of the definitions, which were then considered validated.

CONCLUSION:

The definitions developed for the defining characteristics of three nursing diagnoses were validated with a high level of consensus.

Nursing diagnosis; Neonatal nursing; Signs and symptoms respiratory; Nursing care; Infant; newborn; Patient care planning

OBJETIVO:

Elaborar e validar definições conceituais e operacionais para as características definidoras dos diagnósticos de enfermagem respiratórios, Padrão Respiratório Ineficaz, Troca de Gases Prejudicada e Ventilação Espontânea Prejudicada em recém-nascidos.

MÉTODOS:

Estudo metodológico, de validação conceitual das características definidoras dos três diagnósticos de enfermagem respiratórios por meio da análise de consenso de um comitê de cinco enfermeiras especialistas e de cinco profissionais não enfermeiros, utilizando a técnica Delphi.

RESULTADOS:

Após duas rodadas de avaliação, obteve-se consenso igual ou superior a 80% na totalidade das definições, sendo consideradas validadas.

CONCLUSÃO:

As definições elaboradas para as características definidoras dos três diagnósticos de enfermagem foram validadas com elevado grau de consenso.

Diagnóstico de enfermagem; Enfermagem neonatal; Sinais e sintomas respiratórios; Cuidados de enfermagem; Recém-nascido; Planejamento de assistência ao paciente

Introduction

The activity of diagnosing in nursing has been developing since the early nineteenth century. During the Crimean War, Florence Nightingale and a group of volunteer nurses decreased the mortality rate in military hospitals, through observation, data collection, diagnosis and differential treatment for war wounds, showing that these actions were important for making any judgment about the patient.⁽¹⁾ However, the term nursing diagnosis only emerged in the 1950s, with Louise McManus and, until the 1970s, had little practical application, being included in the nursing process only in 1973.^{( 2 )}

The use of nursing diagnosis in clinical practice provides a systematic basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.⁽³⁾ This structure which approximates the nurse to the object of work requires the use of clinical reasoning and analysis of the observed signs and symptoms, ending in a clinical judgment based on knowledge acquired in academic education, associated with his clinical experience. Diagnosing involves a cognitive process, with inferences drawn about the observed data and as a result, the problem, when interpreted correctly, enables the nurse to direct his actions and anticipate the desired outcomes, improving the quality of nursing care. Its application requires the use of a common language among professionals, in order to assure a unique understanding about ideas and terms that represent the phenomena about which nurses are interested, to outline the actions under their responsibility.^{( 4 )}

In the practice of nursing diagnosis, the understanding of the defining characteristics of the diagnoses may be different among professionals, which may compromise the diagnostic accuracy and, consequently, the quality of nursing care and patient safety, if interventions dissonant to the actual needs are proposed and implemented.^{( 5 , 6 )}

The accuracy of the nursing interpretations about patient responses differ in a significant manner.^{( 7 )} Operational and conceptual definitions provide meaning to a concept and are essential components for understanding the defining characteristics, as they describe what is being assessed and how it should be evaluated. The establishment of guidelines for identification of nursing diagnoses in specific populations, may improve the diagnostic accuracy, promoting the understanding and interpretation of signs and symptoms in a similar manner by all nurses.^{( 6 )}

Several different studies were encountered in the literature dealing with the conceptual and operational definitions of the defining characteristics of some nursing diagnoses, but they were related to adult and pediatric populations, with few in newborn infants.^{( 6 , 8 , 9 )} This fact motivated the development of the present study.

In the decade of the 1950s, the intensive care instituted in the intensive care unit and with mechanical ventilation had a positive impact on survival in this population, followed by disappointing findings in the 1960s, when it was realized that such therapy resulted in structurally damaged lungs. Even today, the improvement in survival of preterm infants, and the outcome of modern neonatal intensive treatment, represent important factors in morbidity and mortality related to chronic lung disease.⁽¹⁰⁾ Many premature infants present difficulties with their adaptation to extrauterine life, because their lungs are structurally immature and, frequently, deficient in surfactant, which leads to the impairment of respiratory function. Still, chronic lung disease of premature newborns is the result of intensive neonatal treatment used to ensure survival.^{( 10 )}

This situation demands specific interventions for treatment and monitoring. In this context, the respiratory nursing diagnoses, that is, those in which the label, definition, signs and symptoms and related factors/etiology have a direct relationship with respiration, become relevant.

Thus, for this study, three respiratory nursing diagnoses that are part of the NANDA International, Inc. (NANDA-I) classification and related to the respiratory pattern and/or changes in normal breathing pattern, were selected: impaired gas exchange (00030-TGP), ineffective breathing pattern (00032-PRI) and impaired spontaneous ventilation (00033-VEP). Other respiratory nursing diagnoses were not included, such as dysfunctional ventilatory weaning response (00034), related to the gradual withdrawal of mechanical ventilation or ventilatory weaning, considering that this represents a situation corresponding to a specific and late phase of treatment of newborns with respiratory distress who require mechanical ventilation. Meanwhile, the nursing diagnosis, ineffective airway clearance (00031), despite being frequently identified in patients on respiratory support and, especially, those on mechanical ventilation, was not part of the study because in the current NANDA-I classification, it is in the class, Physical Injury.^{( 3 )}

The objective of this study was to develop and validate conceptual and operational definitions of the defining characteristics of the respiratory nursing diagnoses, ineffective breathing pattern, impaired gas exchange and impaired spontaneous ventilation in newborns.

Methods

This was a methodological study, conducted from January of 2011 to April of 2012.

The process of validation of conceptual and operational definitions of the defining characteristics proposed by NANDA-I for the three respiratory nursing diagnoses studied in neonates included the analysis of the characteristics, development of definitions, followed by consensual validation by health experts in the area of children and neonates requiring respiratory care.

The construction of the conceptual and operational definitions for each defining characteristic was based on knowledge grounded in the areas of nursing, medicine and physiotherapy. They were then submitted for assessment by two clinical nurses, specialists in intensive care and neonatology.

Aiming at the refinement of definitions of the three nursing diagnoses, the material was submitted to a committee composed of five doctorally prepared nurses, intensive care specialists with more than three years in neonatal and pediatric intensive care and in the use of nursing diagnoses. These experts also developed teaching activities in pediatric and neonatal nursing.

The process of evaluation of the material received by the committee was organized within six meetings, of approximately five hours each, in which the definitions of the defining characteristics were discussed, reformulations were suggested, and, new searches of scientific studies were conducted to obtain consensus about each of them.

After this step, these definitions were sent for analysis by five other professionals, including four physicians and a physical therapist, with clinical experience in respiratory care for neonates and the minimal educational level of a master's degree.

The instrument with the defining characteristics and their conceptual and operational definitions, developed by the committee, was submitted to those experts for analysis and agreement or lack of agreement with the definition and, in case of disagreement, suggestions were requested. In this step the Delphi technique was applied, which consisted of repeated rounds of submission to obtain consensus among the experts. It was established that definitions with agreement equal to or greater than 80% would be considered validated.^{( 11 )}

The development of the study met the national and international standards of ethics in research involving human beings.

Results

Of the 46 defining characteristics proposed by NANDA-I for the three respiratory nursing diagnoses, eight were excluded by the members of the expert committee, as they considered that they were not subject to verification in newborns, and two common signs of respiratory distress in this population were included. In the end, 40 defining characteristics were submitted for validation (Chart 1).

Chart 1
Defining characteristics of respiratory nursing diagnoses

Of the conceptual and operational definitions of the 40 defining characteristics presented to the experts, 12 achieved 100% agreement in the first round and the remaining 28 received suggestions for reformulation of the writing or revision of the concept. Of these, 14 were accepted because the suggestions were related to technical language, for example, substitute alteration of oxygen supply with hypercapnia, when the indicator was related to increased CO2, or modify pulling in of accessory muscle as abnormal thoracic retraction. All of the suggestions as to the format, when relevant, were accepted. The remaining 14 definitions were reformulated according to the suggestions and submitted for a second round of evaluation. As a result of this round, of the 14 defining characteristics, seven obtained 100% agreement and seven had 80% (Chart 2).

Chart 2
Results of expert analysis in the first round of review

At the end of this process, the conceptual and operational definitions of the defining characteristics of the three respiratory nursing diagnoses were considered validated, given the degree of consensus achieved and that are presented in chart 3.

Chart 3
Conceptual and operational definitions of the defining characteristics FAO - Food and Agriculture Organization of the United Nations; WHO - World Health Organization; UNU - United Nations University

Discussion

The limitations of the results of this study are related to the number of specialized professional participants from a university/hospital. On the other hand, the methodology used for the development and refinement of the definitions permitted that two rounds of the administration of the questionnaire were sufficient to achieve high consensus.

Providing conceptual and operational definitions of the defining characteristics for the three respiratory nursing diagnoses represents an important contribution so that clinical nurses can identify, in a precise manner, these signs and symptoms in the newborn. It is a tool that allows the identification of an appropriate nursing diagnosis and enables the proposition of more appropriate interventions for the clinical situation, leading to the safest care for the neonate.

As the 46 defining characteristics of the three nursing diagnoses were analyzed, eight were related to signs or symptoms that were not measurable in the newborn. As neonates do not verbalize what they feel, and only use nasal breathing, the characteristics of headache upon awakening, confusion, visual disturbances, reports apprehension, decreased cooperation, breathing with pursed lips, orthopnea and assumption of three-point positionwere removed. However, two common signs of respiratory distress in this population, encountered in reference literature, grunting and decreased vesicular murmur were included.^{( 12 - 14 )}

Of the 40 defining characteristics submitted, 26 (65.0%) obtained an agreement greater than 80%.

Of these, 12 (30.0%) defining characteristics obtained 100% agreement and 14 (35%) received suggestions, accepted in the first stage of evaluation. Of these, 11 (27.5%) received recommendations regarding format, two (5.0%) related to format and concept, and one (2.5%) only as a concept.

The suggestions as to the format were accepted, since these were grammatical adjustments. The suggestions regarding the concept of three defining characteristics were related to reference values that were confirmed in the literature.

Of the other 14 (35.0%) defining characteristics that achieved less than 80% consensus, in eight (57.0%), the disagreement was related to format, five (35.0%) were about the concept, and one (7.0%) about the format and the concept. After these were structured according to the suggestions and submitted to a second round of evaluation by the experts, these defining characteristics obtained an agreement higher than 80% and were considered acceptable.

Summarizing, of the 40 defining characteristics, thirteen (28%) received suggestions related to the format or concept, nine (22.5%) about the concept, and six (15%) needed to be rewritten. The data seemed to indicate that the preliminary study with the group of experts that developed the definitions resulted in material that adequately reflected the researched subject.

The knowledge acquired with the studies about nursing diagnosis provides a scientific basis for patient care planning of different populations and contributes to nursing actions that are directed to measurable and safer outcomes. Particularly, those with respiratory problems, hospitalized in intensive care units, or those pertaining to specific populations, such as newborns, who require further studies to support the clinical practice of the nurse.

The development of definitions for indicators of nursing diagnoses is recommended by researchers of diagnostic validation. In research, the conceptual and operational definitions allow one to improve the reliability and validity of data related to the studied nursing diagnosis, facilitate replication by other researchers, and provide clear and objective information about what will be assessed and how it will be evaluated. Knowing how the defining characteristics were operationalized is essential to evaluate research, outcomes, conclusions and to identify criteria that can be used in clinical practice.^{( 6 )}

While the conceptual definition expresses the abstract or theoretical sense of the concept being studied, whose final result has the purpose of giving meaning to this concept for those who are studying it, the operational definition specifies the operation that should be completed to collect necessary information in terms of procedures by which the concept should be measured.

The non-use of the operational definition produces inconsistent outcomes on assessments by nurses, when compared to outcomes obtained by nurses who do use them.^{( 6 )}

In clinical practice, the definitions of the defining characteristics of nursing diagnoses provide subsidies for nurses to identify the same signs and symptoms corresponding to the real condition of the child. However, a set of definitions developed for one population is not necessarily appropriate for another, so there is a need for specific studies and distribution of the results for use in clinical practice. It was in this context that the study just described was situated, which, although it was developed based on the opinion of a small number of experts from a single institution, represents an initial contribution to fill this gap.

Despite the fact that several clinical validation studies have been conducted and have reported the development of operational and/or conceptual definitions of the defining characteristics of the diagnoses involved, their content is not available for practical use, suggesting that the use of these definitions are restricted to the field of research.^{( 6 , 15 - 17 )}

The development of a database, with conceptual and operational definitions for the characteristics of nursing diagnoses, represents team work that should be encouraged among nurses who study the NANDA-I taxonomy, and it is a topic of discussion of current research.

Conclusion

The conceptual and operational definitions of the defining characteristics of the nursing diagnoses, ineffective breathing pattern, impaired gas exchangeand impaired spontaneous ventilation were developed, validated and achieved a high degree of consensus.

Acknowledgements

To the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Coordination of Improvement of Higher Education Personnel - CAPES); doctoral scholarship.

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• Collaborations Avena MJ; Pedreira MLG and Gutiérrez MGR, declare that they contributed to the conception and design, analysis and interpretation of data, drafting of the article, relevant critical revision of the intellectual content, and final approval of the version to be published.

Publication Dates

• Publication in this collection
  2014

History

• Received
  09 Sept 2013
• Accepted
  26 Feb 2014