ICNP^® terminology subset for care of women and children experiencing breastfeeding

Abstract

OBJECTIVE

To describe the development of a terminology subset of the International Classification for Nursing Practice for care of women and children in process of breastfeeding.

METHOD:

Methodological study developed in six stages according to the guidelines recommended by the International Council of Nurses.

RESULTS

Seventy-four nursing diagnoses/outcomes and 213 nursing interventions were performed and classified according to the theoretical model Interactive Theory of Breastfeeding.

CONCLUSION

The subset is expected to safely and systematically steer nurses that work in this area, promoting the implementation of the nursing process and quality of care, focusing on women, children and families that are experiencing the breastfeeding process.

Keywords:
Breastfeeding; Nursing diagnosis; Classification; Nursing process; Nursing theory; Terminology.

Resumo

OBJETIVO

Descrever o processo de elaboração de um subconjunto terminológico da Classificação Internacional para a Prática de Enfermagem para assistência à mulher e à criança em processo de amamentação.

MÉTODO

Estudo metodológico desenvolvido em seis etapas seguindo as diretrizes recomendadas pelo Conselho Internacional de Enfermeiras(os).

RESULTADO

Foram elaborados 74 diagnósticos/resultados e 213 intervenções de enfermagem, classificados de acordo com o modelo teórico utilizado, a “Teoria Interativa de Amamentação”.

CONCLUSÃO

Acredita-se que o subconjunto poderá orientar de forma segura e sistemática os enfermeiros que trabalham na área materno-infantil, favorecendo a execução do Processo de Enfermagem e promovendo a qualidade da assistência, centrada na mulher, na criança e na família que estão vivenciando o processo de amamentação.

Palavras-chave:
Amamentação; Diagnóstico de enfermagem; Classificação; Processo de enfermagem; Teoria de enfermagem; Terminologia.

Resumen

OBJETIVO

Describir el proceso de elaboración de un subconjunto terminológico de la Clasificación Internacional para la Práctica de Enfermería para atención de la mujer y el niño en proceso de lactancia.

MÉTODO

Estudio metodológico desarrollado en seis etapas siguiendo las directrices recomendadas por el Consejo Internacional de Enfermeras(os).

RESULTADO

Fueron elaborados 74 diagnósticos/resultados y 213 intervenciones de enfermería, clasificadas según el modelo teórico utilizado, la "Teoría Interactiva de Lactancia".

CONCLUSIÓN

Se considera que el subconjunto podrá orientar de manera segura y sistemática a los enfermeros actuantes en el área materno-infantil, favoreciendo la ejecución del Proceso de Enfermería y promoviendo la calidad de la atención centrada en la mujer, el niño y la familia que están atravesando el proceso de lactancia.

Palabras clave:
Lactancia materna; Diagnóstico de enfermería; Clasificación; Proceso de enfermería; Teoría de enfermería; Terminología

Introduction

Breastfeeding brings several advantages for children, women, families and society. For infants, the benefits occur in the nutritional, physiological, developmental, immunologic, emotional and cognitive states. During breastfeeding mother and child interact, which favors the strengthening of bonds that promote mutual learning and impacts affective, relationship, behavioral, motor, social and cognitive aspects^1-2.

Although breastfeeding is a recurrent and widely researched process, it is necessary to improve the nursing knowledge regarding specialized terminologies and the nursing language related to this phenomenon. Up to this date, there is only one project registered at the International Council of Nurses (ICN) about the design of a terminology subset for breastfeeding based on the International Classification for Nursing Practice (ICNP^®) under the responsability of one of the authors of the present study.

The creation of specialized terminologies originates from a conceptual and theoretical framework. The present study uses the breastfeeding concept expressed as follows: “a process of dynamic interaction in which mother and child interact with each other and the environment to reach the benefits of human milk offered in the breasts to the child, being a unique experience in each event”³. This concept goes beyond the idea of nourishing a child with human milk, encompassing features of a complex and comprehensive phenomenon, with potential biological, psychological, cultural, social, economic and political influences.

Aligned to this concept, the Theory of Interactive Breastfeeding³ aims to describe, explain, predict and prescribe the breastfeeding phenomenon, taking into account the factors that precede and influence it and those that result from this act; thus, it is suitable for the design of terminology catalogs about breastfeeding. This theory was developed deductively, based on Imogene King’s Conceptual Model of Interactive Open Systems and literature evidence, and consists of 11 interrelated concepts: mother-child dynamic interaction, woman’s biological conditions, child’s biological conditions, woman’s perception, child’s perception, woman’s body image, space for breastfeeding, mother’s role, organizational systems for the protection, promotion and support of breastfeeding, family and social authority, and woman’s decision making³.

According to the Interactive Theory of Breastfeeding, to achieve a successful breastfeeding experience it is necessary that mother and child present appropriate biological conditions, such as an adequate anatomy of the breasts, milk production and anatomy and physiology of the child’s stomatognathic system³. It is also understood that feeding the infant with the milk produced in her own body is part of the female nature and considered a divine gift, but also a duty or responsability in the mother’s role that surpasses the will to breastfeed^4-5.

The first days are crucial to the success of breastfeeding, because they are a period of learning for the mother and the child and also the moment when difficulties associated with the activity emerge. At this time, health professionals, relatives and friends must encourage the mother. Therefore, promoting and supporting breastfeeding must be included among primary actions in health programs⁶.

It must be stressed that “theories designed in the nursing field explain the complexity of representative concepts about phenomena that define and limit their area of interest” and that they guide the execution of the nursing process “the methodological instrument through which these theoretical frameworks are applied in the professional practice”⁷.

The systems of standardized language to organize terms or expressions accepted by nurses to describe evaluations, interventions and results are paramount in the nursing process⁸. The International Classification for Nursing Practice is one of these systems and, to encourage its use in nursing recordings in electronic medical forms or in manual systems of information, ICN has been recommending the creation of ICNP^® catalogs, including ICNP^® terminology subsets, care plannings, clinical protocols, guides for clinical practice and nursing minimum data sets⁹. By considering them as technological instruments to be used during the execution of the nursing process, ICN considers that the application of ICNP^® catalogs and, by extension, ICNP^® terminological subsets, facilitates clinical decision-making by nurses, offers support to the systematic documentation of care, fosters research and promotes the formulation of healthcare policies focused on qualifying professional practice¹⁰.

Regarding the design of ICNP^® terminology subsets, ICN advocates that they may be directed to specific groups (individual, family and community), to priorities in the health area (specific health conditions, environments or care specialties), or to nursing phenomena¹¹. Among the specialties recommended by ICN, a few stand out for the purposes of the present study, namely: women’s health, obstetric nursing and family health nursing.

The first description of a method to develop ICNP^® catalogs was issued by ICN in 2008 and has ten steps¹⁰. A paper describing the reduction of this number of steps to six was published in 2010, aligning them to the three components of the life cycle of the ICNP^® terminology: research and development, maintenance and operations, and dissemination and education¹¹.

The present study is based on the ICN recommendation to design subsets of specialties and in the relevance of the use of nursing models and theories. Therefore, the objective of the study is to describe the development of an ICNP^® terminology subset for care of women and children in process of breastfeeding.

Methods

This was a methodological study¹² carried out in six steps: 1) identification of the public and health priorities; 2) collection of relevant terms and concepts for the health priorities; 3) mapping of the concepts identified with ICNP^®; 4) creation of new concepts or adaptation of existing ones to make them clearer; 5) conclusion of the catalog; and 6) promotion of the material¹¹.

To execute the second step, a literature survey was performed in the databases Latin America and Caribbean Center on Health Sciences Information (LILACS) and Medical Literature Analysis and Retrieval System Online (MEDLINE) in May 2015, with the Virtual Health Library descriptors (DeCS) “breast feeding” and “mother-child relations” in English, Portuguese and Spanish. The guiding question was “What are the conditions that influence breastfeeding?”. The inclusion criteria were: original papers, published between 2010 and 2014, in English, Portuguese or Spanish, presenting an abstract and approaching the breastfeeding process. The period of five years was chosen because of the need to include papers that show recent findings about the subject.

The exclusion criteria were: reflection studies, reviews, updates, case reports, letters to journal editors, editorials, theses and dissertations. Two authors conducted the survey independently. The studies that were not available in the mentioned databases were obtained in the full text format at CAPES’ Portal de Periódicos (Portal of Journals, in English). Papers were selected based on analysis of the titles, abstracts and main texts of the publications.

The number of selected papers was 251 for MEDLINE and 28 for LILACS; after applying the criteria and evaluating the abstracts, 68 studies were chosen for thorough reading, among which 52 were considered suitable for being included in the present study. The papers were read exhaustively so that the text could be deeply explored. The excerpts that referred to relevant clinical terms about breastfeeding were highlighted.

Subsequently, a manual mapping was performed with ICNP^® axes to identify the terms related to the breastfeeding process; last, the diagnoses/outcomes and interventions were created according to the ICN guidelines and the norm ISO 18.104:2014 (Informatics in health care: category structures to represent nursing diagnoses and actions in terminological systems^10,13-14).

In the conclusion step, the list of nursing diagnoses/results and interventions was organized according to the concepts of the Interactive Theory of Breastfeeding, because it is understood that the theoretical framework is part of the documentation of important information for nurses, together with the subset organization and presentation.

Taking into account the nature of methodological research and the absence of human beings in the study, it was not necessary to submit the project to approval by the institution’s research ethics committee.

Results

The terminology subset described in the present study identifies as the public the pair mother-child that is experiencing breastfeeding and its families; the health priorities were established as maternal and obstetric nursing and women’s health. In the second step, a literature survey was carried out to identify phenomena and concepts relevant to breastfeeding and that were crucial to the design of the subset. Some of them were: exclusive breastfeeding, predominant breastfeeding, complementary feeding, breastfeeding, bottle feeding, lactation, mother-child position, suction, rooting reflex, attachment, myths, beliefs, positive and negative feelings, pain, fissure, engorgement, translactation, infections, flaccid breasts, mother’s responsability and duty, privacy, embarrassment, shame, knowledge, advantages, decision, mother-child bond, choice, family and professional support, campaign, incentive and child feeding groups.

These concepts were correlated to those derived from the Interactive Theory of Breastfeeding: mother-child dynamic interaction, woman’s biological conditions, child’s biological conditions, woman’s perception, child’s perception, woman’s body image, space for breastfeeding, mother’s role, organizational systems for the protection, promotion and support of breastfeeding, family and social authority, and woman’s decision making. The two procedures in the second step allowed that all the concepts of the grounding theory were used as organizational categories for nursing results and diagnoses related to breastfeeding.

The third step of the subset design consisted of the mapping of the identified concepts based on ICNP^® by selecting terms from the ICNP^® 7-Axis Model issued in 2015¹⁴ that were semantically related to the concepts of the Interactive Theory of Breastfeeding. In this process, 23 terms from the axis “Focus” and ten from the axis “Judgement” were identified and six combined diagnoses were considered relevant to nursing care when it comes to the mother-child pair in the breastfeeding phenomenon.

In the fourth step, the creation of the existing concepts considered not only the ideas from the Interactive Theory of Breastfeeding, but also the whole theoretical framework, because it is understood that different concepts relate in a dynamic process. Therefore, the diagnoses/results and interventions should be organized according to the structure of the nursing theory, not just the empirical basis of breastfeeding.

In the ending step, 74 nursing diagnoses/results were stated, ten of which are available at the 2015 version of ICNP^®. For this set of information, 213 nursing interventions were outlined.

The nursing diagnoses, outcomes and interventions conceptually aligned to the ideas proposed in the Interactive Theory of Breastfeeding were organized in alphabetical order following the ICN guidelines for the presentation of ICNP^® subsets¹⁰. This list is shown in Chart 1.

Chart 1:
Distribution of nursing diagnoses, outcomes and interventions from ICNP^® according to the concepts of the Interactive Theory of Breastfeeding

The nursing diagnoses/results (ND/NR) and interventions (NI) created and distributed according to the concepts of the Interactive Theory of Breastfeeding were classified as follows: ten ND/NR and 34 NI related to the concept mother-child dynamic interaction; 12 ND/NR and 18 NI to the woman’s perception; two ND/NR and 12 NI to the child’s perception; 21 ND/NR and 74 NI to the woman’s biological conditions; six ND/NR and 26 NI to the child’s biological conditions; three ND/NR and six NI to the woman’s body image; three ND/NR and nine NI to space for breastfeeding; three ND/NR and nine NI to mother’s role; six ND/NR and six NI to organizational systems for the protection, promotion and support of breastfeeding; three ND/NR and 11 NI to family and social authority; and three ND/NR and eight NI to woman’s decision making.

The sixth step, which corresponds to the promotion of the subset, is being accomplished with the publication of the present paper and will contribute to the ICN initiatives to disseminate ICNP^® catalogs.

Discussion

The steps of identification of public and health priority and selection of terms and concepts relevant to the chosen priority relate to research and development^10-11. The extraction of concepts from ICNP^® and the literature survey and the inclusion to the concepts of the Interactive Theory of Breastfeeding enabled the nursing diagnoses to be supported on clinical evidence and on a theoretical framework.

According to ICN, specific theoretical or conceptual models are necessary to create nursing diagnoses, results and interventions in terminology subsets¹⁰. Thus, researchers are free to choose guiding models and theories that they consider more aligned with their clinical practice and context. However, the information gathered in the present study reveals that a medium-range theory has a significant potential to help design terminology subsets, taking into account its relatively concrete nature.

The breastfeeding process can be affected by historic, social, cultural and emotional factors from the mother, the child and the family. Consequently, many aspects influence the way women will feed their children and how long breastfeeding will be present^5,15-16. A theoretical model can help organize the phenomena related to breastfeeding without producing reductionist and dichotomized views. In the concept “woman’s perception of breastfeeding”, their perception is influenced by maternal knowledge and experiences of relatives, friends and neighbors, which are transmitted as advices and examples, with favorable or contrary opinions about breastfeeding. These notions originated in common sense are permeated by myths and taboos, which may determine the continuity or not of breastfeeding^6,15,17-18. Because of that, diagnoses associated with the capacity, knowledge and beliefs of women about breastfeeding were created.

The concepts “woman’s and child’s biological conditions” showed a few clinical situations that may interfere negatively in breastfeeding, such as traumas, pain, infections, engorgement, alterations in milk production and in the anatomy and physiology of the newborn’s stomatognathic system^1-5.

The topic “body image” addresses the interference of aesthetic issues in the perception of the woman about breastfeeding. This item is important because when the mother believes that breastfeeding causes flaccid breasts and increased nipples, making them ugly, an unsuccessful breastfeeding process is more likely to happen^16,18. In the concept “space for breastfeeding”, diagnoses related to privacy were performed. This took into consideration that some mothers see breastfeeding as an intimate process and prefer to share it with their partner; they also consider that breastfeeding in public is embarrassing, even if the people close to them are relatives and friends^4,19.

In the concepts “organizational systems for the protection, promotion and support of breastfeeding” and “family and social authority”, the diagnoses were focused on the role of the state, family and society in the breastfeeding process. Family plays a key role and, together with the support of friends and neighbors. It is fundamental to the establishment and continuity of breastfeeding. Similarly, healthcare professionals interfere with the children’s dietary habits, because their orientations, practices and care routines encourage or not breastfeeding, the use of dairy substitutes and bottles^6,15-18.

Thus, it is concluded that breastfeeding presents and originates comprehensive relationships that go beyond the nutritional dimension of the newborn. Without the adoption of a robust structure or theoretical model, there is a risk that nurses do not understand the amplitude of the phenomenon and implement compartmentalized practices.

As presented in the subset, 11 conceptual categories guide the design of nursing diagnoses and results and consequently of nursing interventions. The concepts are derived from and related to the three great systems: personal, interpersonal and social, from Imogene King’s conceptual model³. A medium-reach theory increases the breastfeeding scope, which explains the variety of elements in clinical practice, but also tries to capture the multidimensionality of the nursing work in the interactive breastfeeding process.

The greatest limitation to design the subset and establish generalization limits for it is related to two factors: the complexity of adopting a theory of systemic orientation and the novelty of the Interactive Theory of Breastfeeding and the consequent lack of validation for it. However, the authors recognize the need to submit the proposal to the evaluation of the scientific community.

It must be emphasized that the nursing diagnoses/results obtained through the Interactive Theory of Breastfeeding were not fully explored; other propositions that contemplate aspects of the mother-child relationship can still be elaborated. The specificities of the interventions during breastfeeding make care more complex, revealing the need to plan the nursing care focused on mother-child issues to promote and support exclusive breastfeeding until the sixth month of life²⁰.

The ICNP^® terminology subset for care of nursing mothers and breastfed children was developed as a general and innovative product to guide nurses that assist women, children and families that are experiencing breastfeeding, based on a comprehensive and systemic theoretical framework. It aims to contribute to the systematized documentation of the nursing care, applying terminologies that use the specialized language of nursing practice. Clinical judgement and decision-making are crucial for individualized care to patients and their families¹⁰; therefore, a subset, a decision flowchart and standard operational procedures do not mean the dismissal of expertise and professional competence.

Conclusion

The present study consisted of the creation of an ICNP^® terminology subset with 74 nursing diagnoses/results and 213 nursing interventions for application in nursing processes centered in women, children and families undergoing breastfeeding.

The subset is a useful tool to investigate factors that influence breastfeeding and contributes to the nursing clinical practice in the mother-child area, helping nurses to develop critical thinking and decision-making skills to protect, promote and support breastfeeding. The subset is an evidence-based and easily accessible reference and can contribute to organize individualized care plans.

The results of the present study may guide nurses to develop an ICNP^® terminology subset. Knowledge can be more easily applied in care, teaching and research when diagnoses, outcomes and interventions are clearly defined and organized in a harmonious and significant theoretical framework.

Because it is based on a systemic and interactive nursing theory, the subset helps prevent a reductionist application of the nursing process. It also adds to the systematized documentation and allows the design of electronic medical records using ICNP^® language.

The construct may be useful in the teaching-learning process by connecting the elements of a nursing theory with diagnosis-result-intervention taxonomies. It stresses the value of theoretical frameworks to guide and prescribe aspects of educational and care practices and serves as an example of nursing classifications, encouraging their correct design and use in nursing and health schools and health institutions.

It must be emphasized that the subset must be submitted to a validation process to be carried out by nurses that work in the field, and to a posterior clinical validation in hospitals or clinics with mothers and children that are experiencing breastfeeding.

Acknowledgments

The authors would like to thank the Coordination for the Improvement of Higher Education Personnel (CAPES) for the financial support provided (Process 23038.0091178/2012).

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Publication Dates

• Publication in this collection
  02 July 2018
• Date of issue
  2018

History

• Received
  20 Jan 2017
• Accepted
  13 June 2017