ICNP® nursing diagnostics for people in-home care

Objectives : to identify ICNP ® nursing diagnoses in people attended in a home care program. Methods : cross-sectional study with 131 patients of Home Health Care in a northern municipality of Minas Gerais, Brazil, applied a questionnaire based on Basic Human Needs. It was performed the identification and validation by consensus of specialists with support in Risner’s diagnostic reasoning, of the nursing diagnoses of ICNP ® , version 2019. Results : from 77 nursing diagnoses, most are inserted in the psychobiological needs (n = 66) and refer to the domains Nutrition; Hydration and electrolytic regulation; Cutaneous-mucous integrity; Locomotion, body mechanics and mobility; Body care; and Learning, Sociability, Recreation, and leisure. From total, forty are negative, followed by positive formulations (n = 15), clinical findings (n = 15) and risk (n = 7). Conclusions : a profile of the nursing phenomena common to home care is presented, which can be used by nurses in clinical practice, teaching, research, and management. Descriptors: Nursing; Nursing Diagnosis; Standard Nursing Terminology; Home Health Nursing; Home Care Services. de enunciados positivos (n = 15), hallados clínicos (n = 15) y de riesgo (n = 7). Conclusiones: presenta un perfil de fenómenos de enfermería comunes al cuidado domiciliario, los cuales enfermeros podrán utilizar en la práctica clínica, enseñanza, investigación y gestión. Descriptores: Enfermería; Diagnóstico de Enfermería; Terminología Estandarizada en Enfermería; Enfermería Domiciliaria; Servicios de Asistencia Domiciliaria.


INTRODUCTION
Home care in Brazil has been undergoing advances in recent years, mainly due to the guidelines proposed by the National Policy for Home Care (PNAD) (1) . This service aims at reducing the demand and duration of hospitalizations, providing humanized assistance, continuity of care, valuing the context of life, in addition to the protagonism and autonomy of the patient and family (2) .
Specific indications for such a service are people in a situation of restriction to bed or home temporarily or definitively, or in a degree of vulnerability for which the offer of more timely treatment assistance is considered, such as dementia syndromes and frailty, aggravations and chronic diseases, victims of car accidents or violence (3) .
Nursing is inserted as a profession that is part of the multiprofessional home care team (3) . The nurse's role is highlighted for playing an essential and broad function, emphasizing both relational and educational actions, necessary even in specialized care and the care plan's coordination. He is the professional who seeks the integration and continuity of interventions to be performed (4)(5) .
In order to provide scientific and quality care, nurses must implement the Nursing Process (NP) in their professional practice (6) . It is the profession's clinical method to systematize, standardize nursing care, including in-home care. The NP consists of five stages: the collection of nursing data, nursing diagnosis, nursing planning, implementation, and nursing assessment (6) . It is noteworthy that, when performed in institutions providing outpatient health care services, households, among others, the NP corresponds in those environments as Nursing Consultation (6) .
Studies conducted in Brazil (7) , United States (8)(9) , and Spain (10) sought to identify the in-home care nursing diagnosis profile. However, it is evident that they consist mainly, of old publications, with the absence of theoretical-methodological reference to guide the study, do not contemplate human responses for people in-home care, and use the NANDA International taxonomy (NANDA-I) (7)(8)(9)(10) . Thus, such a study like this is justified, because of the notes mentioned above, the gap of knowledge about the nursing diagnoses of the International Classification for Nursing Practice (ICNP ® ), typical to home nursing care, especially of patients assisted by public home service.
The ICNP ® is a nursing classification system that is under broad global development, with potential applicability in all levels of health care, contributing with gathering, storage, and analysis of information related to nursing care, which confirms the effectiveness of the profession through the observation of nursing-sensitive indicators in clinical practice (11)(12) .
Therefore, this study cooperates to construct a universal nursing language for the assistance to a specific clientele -in this case, people in-home care. Through the identification of diagnostic concepts, the applicability of ICNP ® is tested by the operationalization of stages of the nursing process in research, teaching, and practice, for future prescription of nursing interventions related to problems that are of the nursing domain, to promote health, improve care and to increase the quality of life of patients in-home care.

OBJECTIVES
To identify ICNP ® nursing diagnoses in people followed by an in-home care program.

Ethical Aspects
The study obtained a favorable opinion from the Research Ethics Committee of Montes Claros State University.

Design, period, and place of study
It is a transversal study through stages of NP, nursing data collection, and nursing diagnosis, with an instrument based on theoretical reference. Considering that the nursing process must be based on theoretical support (6) , this study used as a conceptual framework the Basic Human Needs (BHNs), as presented by Brazilian theorist Wanda de Aguiar Horta (13) . This theory is based on the nursing job of helping human beings in a state of equilibrium through assistance to basic needs, conceived as nursing problems (13) , which applies to home nursing care.
The study was carried out with patients registered and assisted by a Home Health Care program in a municipality in the north of Minas Gerais, Brazil, from June 2017 to January 2018. It is noteworthy that the study's locus service is public and does not use a nursing classification system.

Population and criteria of inclusion and exclusion
For convenience, the study used a non-probabilistic sampling technique; the study population consisted of all people registered in the home care service during data collection, totaling 172 users. The inclusion criteria were age equal to or over 18 years; be registered and cared for by the home care program during the data collection period. The study excluded users not found after three recruitment attempts at different times and days of the week; those who evolved to death before data collection; or in hospital admission; people under 18 and those who refused to participate (n = 41; 23.8%). Thus, the final sample was composed of 131 participants.

Study Protocol
The data collection procedure was carried out exclusively by a Nursing undergraduate student at a public university in the state of Minas Gerais, highly trained, and working under the supervision of a professor advisor. The training consisted of a theoretical explanation about medical history and clinical examination, practical training, and reading articles and texts on the subject (14) .
The data were collected employing anamnesis and clinical examination, performed at the patients' homes. The data collection lasted an average of one hour and 30 minutes. For such, it was utilized a systematized instrument, based on professional experience and literature review (6,(9)(10)(11)(12)(13)(14)(15) , containing socioeconomic and clinical-epidemiological variables. A process of refinement of the data collection instrument took place through the assessment of specialists, who evaluated its quality and relevance, and all the suggested changes were accepted, and the final instrument was consolidated by consensus (14) .
The collecting instrument was based on the theoretical and methodological framework of Wanda Aguiar Horta (7,13) , following of ICNP® nursing diagnostics for people in-home care Sousa INM, Silva DVA, Carmo JR, Lopes JR, Félix NDC, Pereira FAF, et al.
the theoretical model of BHNs. This instrument was composed by the following topics: I. Identification data and health history (7) . II. Objective and subjective data related to BHNs -Psychobiological needs, Psychosocial needs and Psycho-spiritual needs (7) .
After data gathering, the instrument containing each patient's information was analyzed by four specialists in August and September 2019; and it was conducted the identification and validation, by consensus, of the nursing diagnoses constant listed as pre-coordinated concepts of ICNP ® , version 2019 (16) .
The process of identifying nursing diagnoses was established on Risner's line of reasoning (17) . Thus, it was possible to apply analytical and synthetic reasoning, considering the critical thinking skills, clinical reasoning (18) , the scientific knowledge, and nurses' experiences in correspondence with inferences elaborated by having items present in the anamnesis and the clinical examination assessment of each patient, as well as the nursing diagnoses listed as ICNP ® pre-coordinated concepts, version 2019 (16) .
For validation of nursing diagnoses, it was applied the technique of validation by consensus (19) , which recommends analysis by a particular group of a minimum of three and a maximum of five clinical nurses in order to establish a consensus opinion (100%) of specialists on the pertinence and relevance of a given nursing diagnosis. The disagreement of one or more specialists conditioned the non-validation of the respective nursing diagnoses (19)(20)(21) .
The criteria for inclusion of specialists were: to be a nurse; to have professional performance or residency in health care, with a minimum of two years of clinical practice assisting Home Care or Primary Care; to be author, co-author, or advisor of studies involving Home Care or Primary Care, nursing process and nursing classifications or taxonomies. Four specialists were selected, considering the geographic proximity to make possible the presential meetings.
It should be mentioned that the validation by consensus occurred in a municipality in northern Minas Gerais, where the four specialists participated in three face-to-face meetings; and, guided by Risner's diagnostic reasoning skills (17) , they identified and validated the nursing diagnoses.

Analysis of results and statistics
The collected data were inserted into an MS Office Excel ® spreadsheet, version 2016. The results' analysis was performed through descriptive statistics, using the absolute (n) and relative (%) frequencies, and the 95% confidence intervals for the relative frequencies. The nursing diagnoses included in ICNP ® 2019 (15) were described by their respective codes, organized in a table according to the theoretical-methodological framework of this study, and discussed according to the relevant national and international literature.
The data collected allowed the identification of 77 nursing diagnoses, listed as pre-coordinated concepts of ICNP ® 2019, validated by specialists. From the total of formulations, 40 are negative, followed by positive formulations (n = 15), clinical findings (n = 15) and risk (n = 7). The ICNP ® 2019 nursing diagnoses identified in this study were classified according to the BHNs, prevailing the formulations s inserted in the Psychobiological Needs (n = 66) ( Table 1).

DISCUSSION
Regarding the predominance of nursing diagnoses classified in psychobiological needs, studies show this result (6,(22)(23)(24) in various research scenarios and different populations. Such fact may be related, in this investigation, to the participants' clinical profile and the professionals' training, impacting the focus of nursing care in meeting psychobiological needs. However, all basic human needs are interrelated and are part of a whole human being (13) . Thus, incorporating a holistic and broad view of the human being is paramount, and the nurse must assist the patient in considering the biopsychosocial and spiritual dimensions, understanding it as an indivisible whole and not merely as the sum of its parts.
The formulation of a nursing diagnosis is a description attributed by the nurse to some decision on a phenomenon that focuses on nursing practice (11) . For ICNP ® , the nursing diagnosis can be classified by assertions such as: positive (represents a chance for a positive or optimistic diagnosis), negative (reflects a damaging diagnosis), clinical finding (indicates an altered state, altered process, altered structure, altered function or altered behavior) and risk (configures a potential for a negative diagnosis) (11)(12) .
Identifying the formulations through the BHN theory allows offering holistic care, centered on the human being and not on the disease, providing planning and implementation of nursing interventions directed to the potential and real needs of in-home care patients.
The need for locomotion, body mechanics, and mobility may be linked to changes in neurological function and neuromuscular impairments of the participants in this study, as indicated by the formulation mobility, impaired (10001219). Home care patients usually present clinical conditions related to the progression of neurodegenerative or cerebrovascular diseases, trauma sequelae due to urban or traffic violence, and fragility (3) . These may result in imbalances, particularly from the need for locomotion, body mechanics, and mobility, such as restriction to the bed or reduction and loss of motor skills. Such conditions and nursing diagnosis have also been evidenced in other studies (7)(8)(9)(10)15) conducted with patients in-home care.
As for the need for body care, the identified nursing diagnoses are directly related to the patients' functionality. The clinical conditions of these people corroborate the difficulty or incapacity to perform or complete self-care activities, which is demonstrated in the nursing diagnoses of self-care deficit (10023410); ability to get dressed, impaired (10000987); ability to perform hygiene, impaired (10000987); ability to bathe, impaired (10000956). Thus, to meet the need for body care, in order to prevent other imbalances, the nursing team must execute the care plan with the collaboration, participation, and involvement of family members or third parties, aiming at health promotion, quality of care, comfort, emotional support, well-being, humanization, and undivided patient care.
A study (25) highlights that frontal lobe deterioration caused by cerebrovascular and other neurological diseases is typical in-home patients. Thus, the conditions of the dependence of patients inhome care can result in imbalances and losses, evidenced by nursing diagnoses related to the need for cutaneous-mucosal integrity, emphasizing the risk of pressure ulcers (or injuries) (10027337). This phenomenon has been recognized as a public health problem, resulting in physical, emotional, social, and economic disorders, and influencing morbidity and mortality. It is a sensitive indicator of nursing practice (26) . Its incidence varies significantly according to the patient's clinical environment and characteristics, being higher in acutely hospitalized patients who need long-term care, as is the case of those in-home care (27) .
To avoid situations or conditions resulting from imbalances in need for cutaneous-mucous integrity, the nurse must keep vigilance especially regarding the risk factors for pressure injury, such as the presence of humidity, friction, shear, friction, age extremes, bone prominences, immobilization, nutritional deficiencies, reduction or loss of motor or sensitivity (26)(27) . In this context, to reduce the condition, the nurse needs to assist the patient in the in-home context with the best care practices based on scientific evidence, providing him/her and the family members with autonomy in the care process.
The need for hydration and electrolytic regulation, like in other studies (7)(8)(9)(10) , highlights the nursing diagnosis of fluid intake, impaired (10029873). It is relevant that in-home care patients may present body fluids imbalance due to impaired fluid intake, which may happen due to barriers or limitations related to the patient's clinic, often related to the impossibility of verbalizing thirst, dependence, and bed restriction (7,28) .
The psychosocial aspects stand out the nursing diagnosis of the family process, effective (10025232). When considering the needs for learning, sociability, recreation, and leisure, it is evident that the clinical profile of patients in-home care has an impact on the difficulty or unfeasibility of the patient to participate in leisure and recreation activities outside their home, causing the narrowing of social bonds (29) . The present study evidence this situation by nursing diagnosis socialization, impaired (10001022). On the other hand, the diagnosis family process, effective (10025232), demonstrates establishing and strengthening family bonds, confirming the importance of family support and participation in coping with imbalances. From this perspective, it is possible to highlight the foundations of PNAD (3) by providing humanized care, with the valorization of the patient's life context and active participation of the family in the planning and implementation of care plans.
Regarding the psychospiritual needs, there is a lack of expressiveness, which can be related to losses both in the patient's need of communication, affirmed by the nursing diagnosis communication, impaired (10023370) and in the principle of fostering discussion on the theme of religiosity/spirituality during academic training, which reinforces the concept of reorientation towards comprehensive care, with a holistic and broad view of the human being, considering the biopsychosocial and spiritual aspects.
The results of this study show the complexity of nursing phenomena evident in-home care, in which the nurse is inserted as an adequate health professional to understand the individual, environment, and community in all its complexity, and should register the assistance using a nursing classification system and, thus, contribute with the generation of health indicators from nursing practice. In the same way, when using a theory to guide care, the nurse maintains the dynamic balance, with actions to prevent imbalances and reverting them in balance in time, space, and environment in which the person is inserted, or that is, at home.

Study Limitations
Because it is a cross-sectional study, outcome and exposure were measured simultaneously, and it is not possible to identify the cause and effect correlations. It is a population of a specific location. Finally, despite the sampling strategy used and the effort to collect (data from) all patients, the final sample size is a limit that produced an extension of the confidence intervals.

Contributions to the fields of Nursing, Health and Public Policy
The identification of nursing diagnoses for specific clientele (in this case, in-home care) collaborates in the description, comparison, and representation of the domain of nursing practice to promote quality care based on scientific evidence and assist nurses in the registration of information based on data for use in practice, management, education, and research. As a contribution in the context of health and nursing, there is the proposal to standardize a professional language, contributing to the applicability of the nursing process in the clinical practice of nurse in-home care, with potential for the construction of accurate interventions for this population group and the future structuring of a terminological subset of ICNP ® aimed at home nursing care.

CONCLUSIONS
There was identified seventy-seven nursing diagnoses through the pre-coordinated concepts in IPCE ® 2019, which involved, with greater prevalence, the abilities of mobility, self-care, vulnerability to skin alterations, and family processes. From the total formulations, 40 are negative, 15 positive, 15 clinical findings and 7 risk formulations.
The identified nursing diagnoses were classified according to the Basic Human Needs, prevailing the formulations inserted in the Psychobiological Needs and the domains Nutrition; Hydration and electrolytic regulation; Cutaneous-mucous integrity; Locomotion, body mechanics and mobility; Body care; and Learning, sociability, recreation, and leisure.
The present study describes a profile of the nursing phenomena common to home care, which can be used by nurses in clinical practice, in teaching, in research and in health care management, considering the particularities of the varied populations and cultures.