ICNP^® terminological subset for the alcoholic person

Abstract

Objective

To develop and validate a terminological subset of the International Classification for Nursing Practice (ICNP^®) for alcoholics.

Methods

Descriptive study conducted in the following steps: 1) Identification of the signs and symptoms of alcoholism through analysis of medical records of people with alcohol dependence syndrome in outpatient follow-up and analysis of official documents on alcoholism; 2) Cross-mapping with terms of the Focus axis of the ICNP^® 2017; 3) Construction of statements of nursing diagnoses, outcomes and interventions and operational definitions; 4) Validation of the statements of nursing diagnoses, outcomes and interventions; and 5) Organization and structuring of the ICNP^® terminological subset for alcoholics according to Betty Neuman’s Theoretical Model.

Results

Twenty-eight nursing diagnoses and outcomes and 211 nursing interventions for the care of alcoholics were validated by specialist nurses and structured according to Betty Neuman’s Theoretical Model.

Conclusion

The developed ICNP^® terminology subset can assist in critical thinking and decision making and provide evidence-based care and a unified nursing language.

Alcoholism; Nursing process; Nursing diagnosis; Nursing care; Standardized nursing terminology

Resumo

Objetivo

Elaborar e validar um Subconjunto terminológico da Classificação Internacional para Prática de Enfermagem (CIPE^®) para a pessoa alcoolista.

Métodos

Pesquisa descritiva realizada nas seguintes etapas: 1) Identificação dos sinais e sintomas do alcoolismo por meio de análise de prontuários de pessoas com síndrome de dependência alcoólica em seguimento ambulatorial e pela análise de documentos oficiais sobre o alcoolismo; 2) Mapeamento cruzado com os termos do eixo FOCO da CIPE^® 2017; 3) Construção dos enunciados diagnósticos, resultados e intervenções de enfermagem e construção das definições operacionais; 4) Validação dos enunciados diagnósticos, resultados e intervenções de enfermagem e 5) Organização e estruturação do Subconjunto Terminológico CIPE^® para pessoa alcoolista segundo o modelo teórico de Betty Neuman.

Resultados

Foram validados pelos enfermeiros especialistas 28 diagnósticos e resultados de enfermagem e 211 intervenções de enfermagem para o cuidado à pessoa alcoolista, os quais foram estruturados segundo o Modelo Teórico de Betty Neuman.

Conclusão

O subconjunto terminológico CIPE^® elaborado poderá auxiliar no pensamento crítico e na tomada de decisão, propiciando um cuidado baseado em evidências e linguagem de enfermagem unificada.

Alcoolismo; Processo de enfermagem; Diagnóstico de enfermagem; Cuidados de enfermagem; Terminologia padronizada em enfermagem

Resumen

Objetivo

Elaborar y validar un subconjunto terminológico de la Clasificación Internacional de la Práctica de Enfermería (CIPE^®) para la persona alcohólica.

Métodos

Investigación descriptiva realizada en las siguientes etapas: 1) Identificación de los signos y síntomas del alcoholismo mediante el análisis de historias clínicas de personas con síndrome de dependencia alcohólica bajo seguimiento ambulatorio y mediante el análisis de documentos oficiales sobre alcoholismo. 2) Mapeo cruzado con los términos del eje Foco de la CIPE^® 2017. 3) Construcción de los enunciados diagnósticos, resultados e intervenciones de enfermería y construcción de las definiciones operativas. 4) Validación de los enunciados diagnósticos, resultados e intervenciones de enfermería. 5) Organización y estructuración del Subconjunto Terminológico CIPE^® para la persona alcohólica según el modelo teórico de Betty Neuman.

Resultados

Los enfermeros especialistas validaron 28 diagnósticos y resultados de enfermería y 211 intervenciones de enfermería para el cuidado de la persona alcohólica, que fueron estructurados según el modelo teórico de Betty Neuman.

Conclusión

El subconjunto terminológico CIPE^® elaborado podrá ayudar al pensamiento crítico y en la toma de decisiones, y así proporcionar un cuidado basado en evidencias y lenguaje de enfermería unificado.

Alcoolismo; Proceso de enfermería; Diagnóstico de enfermería; Cuidados de enfermeira; Terminología normalizada de enfermería

Introduction

Alcoholism is one of the greatest public health problems both in the international scenario and in Brazil.(¹) In 2018, the World Health Organization (WHO) released the report on alcohol consumption in the world and about some advances achieved with policies for Alcohol Abuse Reduction adopted by several countries.(²)

Based on the above, the Ministry of Health proposes actions aimed at harm reduction as a main strategy, considering the subject’s uniqueness and the objective to reduce social, individual and community vulnerabilities.(³) As nurses assume an important role in care and rehabilitation of these individuals within this context,(⁴) they must be prepared to offer qualified care.

In order to instrumentalize their practice, nurses have the Nursing Process (NP), which systematically organizes their actions into five interrelated and interdependent steps.(⁵) The NP implementation requires the use of classification systems that represent a unified language and document the nursing care practice. Among the taxonomies, the International Classification for Nursing Practice (ICNP^®), approved by the International Council of Nurses (ICN), is a unifying landmark of language that provides the documentation of nurses’ clinical practice, greater visibility to nursing actions and nursing data for information systems.(⁶)

To this end, the ICN has stimulated the construction of Terminological Subsets or ICNP^® Catalogs, which are sets of statements of nursing diagnoses, outcomes and interventions directed to a certain health condition or context of care and nursing phenomena with the aim to facilitate the use of the classification, and support nurses in their decision making through a standardized language that can describe the nursing practice.(⁶,⁷) In view of the above, the objective of this study was to develop and validate a terminological subset of the ICNP^® for alcoholics.

Methods

This is a descriptive study in which were followed the steps proposed by Nóbrega et al.(⁷) for the development of ICNP^® terminological subsets. The study was developed in five steps: 1) Identification of the signs and symptoms of alcoholism; 2) Cross-mapping of the terms identified with terms of the Focus axis of the ICNP^® 2017; 3) Construction of statements of nursing diagnoses, outcomes and interventions (ND/NO/NI) and operational definitions; 4) Validation of ND/NO/NI; 5) Organization and structuring of the subset.

In the first step, three trained researchers searched for signs and symptoms of alcoholism in medical records of users in outpatient follow-up and reviewed official documents related to alcoholism. The identified terms were organized in a Microsoft Excel 2010^® spreadsheet in alphabetical order.

In the second step, the identified terms were processed by cross-mapping, that is, analyzed and compared manually with terms of the Focus axis of the ICNP^®.

In the third step, the statements of nursing diagnosis and outcomes were constructed according to the ICN and the ISO 18.104:2014(7).(⁸) For each nursing diagnosis and outcome, the operational definition was developed.

In the fourth step, the content validation of nursing diagnoses, outcomes and interventions was performed by expert nurses selected based on the following criteria: nurse; clinical experience of at least three years in the area of mental health with a focus on alcoholics and the minimum degree of specialization in mental health.

For sample calculation, a confidence level of 80% and a sample error of 15% were considered, resulting in 27 experts.(⁹) Nurses were sent an invitation letter, the Informed Consent form and Google^® online tool. In the validation of nursing diagnoses, outcomes and interventions, expert nurses expressed agreement by marking ‘X’ on a psychometric Likert scale containing: 1) Nothing relevant; 2) Not very relevant; 3) Quite relevant and 4) Very relevant. Afterwards, data were tabulated in the Microsoft Excel^® 2010. For each nursing diagnosis and outcome validated, nursing interventions were constructed and went through the same validation process by expert nurses. In data analysis, the Content Validity Index (CVI) method was used and the diagnoses, outcomes and interventions that obtained agreement of at least CVI ≥ 0.80 were considered validated.

In the fifth step, organization and structuring, the diagnoses were classified according to Betty Neuman’s Theoretical Model and categorized according to stressors as intrapersonal, interpersonal and extra-personal.(¹⁰)

The study complied with Resolution number 466/2012(¹¹) of the National Health Council, which regulates research with human beings and was approved by the Research Ethics Committee of the HUCAM-UFES under number CAAE 91900218.7.0000.5071.

Results

In the first step, 673 terms related to the signs and symptoms of alcoholism were identified. After the normalization process, that is, graphic corrections - gender, number, degree and uniformity with terms of the ICNP^® 2017, 493 terms remained. The spreadsheet with the common terms was grouped by similarities of clinical changes detected in the alcoholic person and concepts explained in the literature, resulting in 71 terms with their frequencies. Then, we performed the cross-mapping with terms of the ICNP^® 2017 Focus axis, eliminated repetitions and synonyms, and 29 terms remained.

The experts of the first and second step were women (81.4% - 88.8%), lived in the southeastern region (59.2% - 66.6%), graduated from a public institution (70.3% - 85.1%), and predominantly nurses holding a PhD (51.8% - 59.2%). Regarding knowledge of nursing classifications during undergraduate studies, NANDA-I was the most studied (62.9% -74.0%), followed by the ICNP^® (14.8% - 7.4%).

After the content validation process, the statements of 28 nursing diagnoses, 28 nursing outcomes and 211 nursing interventions were validated. The organization of statements in the ICNP^® terminology subset followed the recommendations of the ICN. They are distributed according to the stressors of Betty Neuman’s Theory presented in chart 1.

Chart 1
ICNP® terminological subset for alcoholic persons

Betty Neuman’s Theory
Intrapersonal Stressors
Nursing Diagnoses/Outcomes
Hallucination	Suicidal Ideation
Anxiety	Impaired memory
Self-Care Deficit	Nausea
Low self esteem	Risk for Situational Low Self-Esteem
Agressive Behavior	Risk for seizure
Isolation behavior (or withdrawal, introversion)	Impaired sleep
Confusion	Suicide attempt
Seizure	Tremor
Delirium	Sadness
Disorientation	Vomiting
Peripheral edema
Depressed humor
Nursing Interventions
Counselling about Fears	Obtaining Data on Self-Esteem
Administering Medication	Obtaining Data on Ability to Perform Care
Supporting Caregiver	Obtaining Data on Aggressive Behavior
Assessing Adherence to Therapeutic Regime	Obtaining Data on Edema
Assessing Edema	Obtaining Data on fatigue
Assessing Therapeutic Regime	Obtaining Data on Depressed Mood
Evaluating Response to Medication	Obtaining Memory Data
Assessing Ability to Communicate Feelings	Obtaining Data on Nausea
Demonstrating Relaxation Technique	Obtaining Data on Health and Social Care Needs
Referring to Emergency Service	Obtaining Data on Guidance
Referring to Psychology Service	Obtaining Data on Hygiene standard
Referring to Support Group Therapy	Obtaining Data on Sleep
Encouraging Positive Affirmations	Obtaining Data on Sadness
Establishing Trust	Guiding Caregivers about Alcohol Withdrawal Symptoms
Facilitating Access to Treatment	Guiding Family on Delirium
Facilitating Family Ability to Participate in the Care Plan	Guiding Family on Hygiene Standard
Facilitating Ability to Communicate Feelings	Guiding Family on Fluid Therapy (or Hydration)
Facilitating Ability to Communicate Needs	Counselling Patient
Facilitating Alcohol Abuse Recovery	Counseling About Drug Abuse
Screening for Alcohol Abuse	Guiding on Symptom Control
Ensuring Continuity of Care	Guiding on Diet
Managing Anxiety	Guiding on Edema
Managing Aggressive Behavior	Guiding on Hygiene
Managing Negative Behavior	Guiding on Nausea Management (Control)
Managing Delirium	Guiding on the management (control) of withdrawal symptoms (withdrawal or withdrawal of something)
Managing Impaired Coping Process	Guiding on Home Security
Managing Withdrawal Symptom (Withdrawal or Withdrawal of Something)	Guiding on Sleep
Managing Vomiting	Guiding on Reality Orientation Therapy
Identifying Psychosocial Status	Prioritizing Treatment Regime
Identifying Altered Perceptions	Promoting Medication Adherence
Implementing Suicide Precautions	Promoting Family Support
Implement seizure management regime	Promoting Social Support
Implement Safety Regime	Promoting Self-Esteem
Managing Delirium	Promoting Health Seeking Behavior
Managing Crisis	Promoting Self Management of Symptom
Managing Withdrawal Symptom	Promoting Effective Family Process
Monitoring Medication Adherence	Promoting Positive Relationships
Monitor Neurological Status	Promoting Use of Memory Technique
Monitoring Confusion	Providing Emotional Support
Obtaining Data on Abstinence (Withdrawal or Withdrawal of Something)	Providing Safety Devices
Obtaining Data on Alcohol Abuse	Providing Bedtime Routine
Obtain Data on Drug Abuse	Reinforcing Impulse Control
Obtaining Data on Acceptance of Health Condition	Reinforcing Constructive Decisions on Health Needs
Obtaining Data on Adherence to Safety Regime	Reporting Status to Family Member
Nursing Interventions
Obtaining Data on Adherence to Medication Regime	Assessing the Characteristics of Vomiting
Obtaining Data on Adherence to Therapeutic Regime	Assessing Possible Causes of Edema
Obtaining Data on Emotional Support
Continuous Surveillance
Interpersonal Stressors
Nursing Diagnoses/Outcomes
Drug Abuse	Drug Dependence (smoking)
Alcohol Abuse	Low Knowledge of Alcohol Abuse
Nursing Interventions
Counselling Patient	Identifying the Family and Social Support Network
Counselling About Alcohol Use	Identifying Psychosocial Status
Helping to identify situations related to the desire to drink	Identifying Altered Perceptions
Supporting Family	Monitoring Withdrawal (Withdrawal or Withdrawal of Something)
Evaluating Psychosocial Response to Plan of Care	Obtaining Data on Abstinence (Withdrawal or Withdrawal of Something)
Referring to Support Group Therapy	Obtaining Data on Alcohol Abuse
Facilitating Access to Treatment	Obtaining Data on Drug Abuse
Facilitating Family Ability to Participate in the Care Plan	Obtaining Data on Adherence to Medication Regime
Facilitating Ability to Communicate Needs	Obtaining Data on Adherence to Treatment Regime
Facilitating Ability to Communicate Feelings	Providing Guidance on the Development of a Goal Plan to Reduce and stop Alcohol Abuse
Facilitating Ability to Participate in Care Planning	Counselling About Alcohol Use
Facilitating Alcohol Abuse Recovery	Counselling About Drug Abuse
Screening for Alcohol Abuse	Guiding on Secondary Smoking Exposure (Passive)
Screening Substance Abuse	Guiding on Management (control) of Withdrawal Symptoms (withdrawal or withdrawal of something)
Screening for Depressed Mood	Reporting Status to Family Member
Managing Anxiety
Extra-personal Stressors
Nursing Diagnoses/Outcomes
Lack of Social Support	Lack of Family Support
Nursing Interventions
Referring to Family Therapy	Obtaining Data on Health and Social Care Needs
Facilitating Family Ability to Participate in the Care Plan	Obtaining Family Process Data
Facilitating Ability to Communicate Needs	Guiding on Family Process
Monitoring for Impaired Family Coping	Promoting Family Support
Obtaining Data on Social Support	Promoting Social Support
Obtaining Data on Family Knowledge in Relation to the Disease	Promoting Effective Family Communication

Discussion

The Theoretical Model adopted in this study considers the person as an open system in continuous interaction with constantly changing internal and external forces in the environment, moving all the time towards a dynamic state of balance, harmony or wellbeing, or even towards illness in varying degrees. Thus, the system stability is based on the patient’s reactions to stress by the interaction of five variables: physiological, psychological, sociocultural, developmental and spiritual.(¹⁰) Components of the Neuman Model are the stressors and the reaction to such stressors. According to this theory, stressors are classified as intrapersonal (forces occurring within each individual, such as anger and internal conflicts), interpersonal (those occurring between individuals and arising from the relationship between people) and extra-personal (those occurring outside the individual, such as unemployment or the inability to perform tasks).(¹⁰) The ICNP^® terminological subset for alcoholics includes nursing diagnoses, outcomes and interventions validated and structured according to stressors of the theoretical model adopted.

The step of validation has the greatest fragility because to date, there is no methodological proposal published by the ICN to perform the validation, so those who wish to conduct this step develop the proposals based on processes from other classifications in the nursing field.(⁷)

In the present study, 28 out of the 32 diagnoses and outcomes were validated; as well as 211 out of the 219 proposed interventions. This fact demonstrates the importance of reviewing medical records and the literature on the theme in order to build a broad overview of the signs and symptoms of alcoholism.

Among nursing diagnoses, specifically considering intrapersonal stressors, the “Self-Care Deficit” diagnosis was unanimously validated by specialists (CVI = 100%) and is characterized by the individual’s conditions to take care of what is necessary to maintain oneself, ensuring survival, dealing with basic, individual and essential needs, and activities of daily living.(¹¹-¹³) As in alcoholism people have the tendency to neglect self-care, in order to achieve a satisfactory result, nursing interventions should encourage the individual to seek health-seeking behavior strategies. The adoption of strategies by the nursing professional will allow the balance of individuals by considering their uniqueness when controlling the stressor agent that was identified in the first step of the nursing process.

Other highlighted nursing diagnosis were “Suicidal Ideation” and “Suicide Attempt”, validated with CVI of 0.88 and 0.96, respectively. Suicide attempts should be considered as a warning sign for professionals, and services should be structured and capable of promoting a support network. In this context, nurses must be able to identify the patient’s signs and symptoms for the promotion of targeted and effective treatment. A study conducted with nurses in primary care with the aim to describe their actions for suicide prevention and to discuss the work process focused on prevention revealed that prevention actions should be inserted in nurses’ work process.(¹³) Alcohol abuse is among the main risk factors for suicide, therefore, nursing interventions in the face of these risk situations involve actions to build a support network, along with specialized services, family members and caregivers in a flexible care plan with continuous monitoring.(¹⁴)

In the category of interpersonal stressors, four nursing diagnoses and outcomes that affect the system were categorized. The nursing diagnosis and outcomes “Drug Dependence (Smoking)” was validated with an Agreement Index of 0.92 and refers to the impulse that leads the person to use a drug continuously (always) or periodically (frequently) to obtain pleasure, and also to relieve tension, anxieties, fears and unpleasant sensations.(¹⁵) The literature showed a relationship between smoking and alcoholism in a study of medical students from four medical schools in the city of Fortaleza, Northeast Brazil, in which alcohol experimentation occurred earlier among students who smoked.(¹⁶) Note that when alcoholism and smoking occur together in the same individual, treating both becomes even more difficult. To this end, nursing interventions must have the purpose of helping and supporting the patient to assume responsibility for improving the quality of life, thereby achieving system balance. It is important that nurses expand their work to family members and encourage patients to participate in support groups, cultural institutions and leisure resources in order to expand their possibilities of healthy belonging.(¹⁷)

Finally, in the category of extra-personal stressors, two nursing diagnoses and outcomes were organized based on the stressors that imbalance the individual’s system. As stressors in this category are forces occurring outside the system and act on the individual(¹⁰), nursing interventions should contribute to build a social network that prioritizes health promotion. The nursing diagnosis “Compromised Family Support” was built from important stressors that destabilize the individual’s system, such as family relationship, family quarrels and conflicts. Family involvement in the rehabilitation of the alcoholic person is important, because the exposed problem can be faced by proposing interventions to reduce alcohol abuse. In a study on the impact exerted by an educational intervention on nurses’ attitudes and knowledge before alcohol use and associated problems, the professionals who received training to work with drug addicts demonstrated more positive attitudes towards alcohol users.(¹²) Thus, the nurse’s attitude towards the patient will guide the entire course of treatment.(¹³)

Care actions for people who suffer from alcoholism are a challenge for health professionals,(¹⁰) therefore, demand the adoption of new approaches to these individuals and allow nurses’ reflection on their clinical practices.

A limitation of the study was the difficulty in composing the numbers of nurses with experience with the ICNP^® and alcoholism for the step of content validation and the need to perform the clinical validation of the subset with people affected by alcoholism.

Conclusion

The objective of this study was achieved from the development and validation of the terminological subset of the ICNP^® for alcoholics. The nursing diagnoses, outcomes and interventions can be an easy-access reference for nurses in the development of the individualized care plan for alcoholics. Although the subset does not replace nurses’ clinical reasoning, it is a facilitator for an evidence-based practice.

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Publication Dates

• Publication in this collection
  26 Nov 2021
• Date of issue
  2021

History

• Received
  17 Jan 2020
• Accepted
  2 Dec 2020