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Applicability of the NANDA-I and Nursing Interventions Classification Taxonomies to Mental Health Nursing Practice Emi da Silva Thomé, RN, MSN, Renata Cardoso Centena, RN, Andressa da Silva Behenck, RN, Maiko Marini, RN, MSN, and Elizeth Heldt, RN, PhD Emi da Silva Thomé, RN, MSN, is an Assistant Nurse at the Porto Alegre Clinical Hospital, Porto Alegre, RS, Brazil, Renata Cardoso Centena, RN, is a Graduate of the School of Nursing, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil, Andressa da Silva Behenck, RN, is an Assistant Nurse at the Porto Alegre Clinical Hospital, Porto Alegre, RS, Brazil, and a Master’s Student at the School of Nursing, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil, Maiko Marini, RN, MSN, is an Assistant Nurse at the Municipal Health Department of Caxias do Sul, Caxias, RS, Brazil, and Elizeth Heldt, RN, PhD is an Adjunct Professor in the Graduate School of Nursing/UFRGS, Porto Alegre, Brazil.
Search terms: Mental health, nursing appointment, nursing care systematization, nursing diagnoses and intervention Descritores: Consulta de enfermagem, sistematização da assistência de enfermagem, diagnóstico e intervenções de enfermagem, saúde mental Author contact: [email protected], with a copy to the Editor: [email protected]
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PURPOSE: To assess the applicability of the systematization of nursing care (NCS) to outpatient nursing appointments using the NANDA-I and Nursing Interventions Classification (NIC) taxonomies. METHODS: Data were collected from 40 patients who had appointments with a nurse who specialized in mental health. Nursing diagnoses (NDs) and interventions were classified using the NANDA-I and NIC taxonomies, respectively. FINDINGS: A total of 14 different NDs were detected (minimum of one and maximum of three per appointment). The most frequently made diagnoses were impaired social interaction (00052), anxiety (00146), and ineffective self-health management (00078). A total of 23 nursing interventions were prescribed (approximately two per appointment), of which the most frequent were socialization enhancement (5100), self-care assistance (1800), and exercise promotion (0200). Significant associations were found between the most frequently detected NDs and the most commonly prescribed interventions (p > .05). CONCLUSIONS: The NCS through the use of classification systems allows mental health nurses to better identify and assist poorly adjusted patients. IMPLICATIONS FOR NURSING PRACTICE: The assessment of the applicability of the NCS to different areas of health care and types of medical assistance contributes significantly to the quality of nursing care. OBJETIVO: verificar a aplicabilidade da Sistematização da Assistência de Enfermagem (SAE) em consulta de enfermagem de saúde mental ambulatorial utilizando as taxonomias NANDA-I e NOC. MÉTODO: Os dados foram obtidos de 40 pacientes que consultaram com enfermeira especialista do programa de enfermagem em saúde mental. Os NDs e as intervenções foram definidos com base nas taxonomias da NANDA-I e da NIC, respectivamente. RESULTADOS: Foram identificados 14 diagnósticos de enfermagem (DE) diferentes (mínimo de 1 e máximo de 3 por consulta) e os mais frequentes foram: interação social prejudicada (00052), ansiedade (00146) e autocontrole ineficaz da saúde. Dentre as intervenções de enfermagem foram identificadas 23 (aproximadamente 2 por consulta) e as mais frequentes foram: aumento da socialização (5100) e assistência no autocuidado (1800). Foi verificada associação significativa entre os ND e as intervenções mais frequentes (p < .05). CONCLUSÕES: A SAE em consulta de enfermagem de saúde mental ambulatorial possibilita identificar as respostas desadaptadas e determinar as intervenções prioritárias. IMPLICAÇÕES PARA A PRÁTICA EM ENFERMAGEM: Avaliar a aplicabilidade da SAE em diferentes especialidades e em diferentes modalidades de atendimento contribui para a qualificação do cuidado em enfermagem. © 2014 NANDA International, Inc. International Journal of Nursing Knowledge Volume 25, No. 3, October 2014
E. S. Thomé et al. Outpatient clinics play an important role in providing multidisciplinary services to nonhospitalized patients. Over recent years, these services have been made increasingly available in an attempt to reduce hospital admission rates and increase the efficacy of preventive and health promotion programs. However, studies suggest that nurse practitioners at these services have been unable to meet patient demand (Osinaga, Furegato, & Santos, 2007), especially in cases of mental illness, which are highly prevalent and insufficiently addressed by health services (Caixeta & Moreno, 2008). In southern Brazil, university hospitals comprise an important part of the health system, as they are able to provide assistance to patients at different stages of treatment. Psychiatric wards are available for acute cases, psychosocial care centers (CAPS) provide rehabilitation services, and outpatient clinics assist with treatment maintenance through nursing appointments (Franzen et al., 2012). Outpatient nursing care is largely managed by the Mental Health Nursing Program, a specialized public health service developed to assist patients with mental disorders. The program targets patients with mental disorders or maladaptive functioning and their families, and assists them through nursing appointments whose main therapeutic tool is the nursing process itself (Heldt & Rodrigues, 2006). The operationalization of the nursing process was facilitated by the development of the NANDA-I taxonomy for coding nursing diagnoses (NDs) (Herdman, 2010) and the Nursing Interventions Classification (NIC) (Dochterman & Bulechek, 2008), which, together, led to the systematization of nursing care (NCS). Mental health nursing interventions based on NDs may be implemented so as to prevent or treat diseases, or for health promotion purposes. The NIC taxonomy is based on group nursing interventions to improve health outcomes (Dochterman & Bulechek, 2008). In outpatient health visits, interventions to improve coping skills are developed with the patient through goal setting and agreements (Heldt & Rodrigues, 2006). In the context of these interventions, the implementation of a diagnostic system in clinical practice allows nurses to identify with greater clarity the patient care needs for which they are responsible (Cianciarullo, Gualda, Melleiro, & Anakubi, 2005). A number of studies have assessed the applicability of the NANDA-I and NIC taxonomies to mental health settings (Frauenfelder, Müller-Staub, Needham, & Van-Achterberg, 2011; Laguna-Parras, Jerez-Rojas, GarcíaFernández, Carrasco-Rodríguez, & Nogales-VargasMachuca, 2013). However, most of these studies were conducted with inpatient populations, which are quite distinct from outpatient samples. The fundamental difference between these two settings is the duration of the interaction between the nurse and the patient, which is approximately 24 hr in inpatient settings but only 40 min, on average, in outpatient settings. The stages of patient care also differ between these two settings. While for inpatients the focus of medical interventions is mostly on acute signs and symptoms, outpatient treatments focus on the
Mental Health Nursing and Taxonomies maintenance of well-being and health promotion (Franzen et al., 2012). A study of outpatient mental health care found that the NCS improves the efficacy of nursing appointments, as it allows the nurse to know and work with the patient, his family, and the community, as well as to promote and maintain health (Beteghelli, Toledo, Crepschi, & Duran, 2005). However, the study was qualitative and focused only on the description of the most frequent diagnoses. A recent review of the NANDA-I–NIC taxonomies in mental health noted the scarcity of publications on the use of these taxonomies in mental health settings. Of the articles included in this review, 10 examined the frequency of different NANDA-I and/or NIC diagnoses, and 4 assessed care plans. The authors of this study also discussed the lack of studies in this area (Escalada-Hernández, MuñozHermoso, & Marro-Larrañaga, 2013). Therefore, to address this gap in the literature, the present study sought to assess the applicability of the NCS to outpatient nursing appointments using the NANDA-I and NIC taxonomies. Methods This cross-sectional study was performed in a university hospital, which, in addition to providing medical services, was involved in teaching and research activities. The participating patients were referred from other health units due to maladaptive responses to stress or psychiatric diagnoses (Heldt & Rodrigues, 2006). The sample consisted of 40 consecutive patients who attended nursing appointments between February and March 2010. All participants were over 18 years old. Appointments lasted an average of 40 min and were conducted by a nurse who specialized in mental health. The NDs and interventions were classified using the NANDA-I and NIC taxonomies, respectively. During the appointment, nurses performed a mental state examination (MSE), an anamnesis, and a physical examination on each patient (Franzen et al., 2012; Heldt & Rodrigues, 2006). The alterations in psychological functioning, as well as the signs and symptoms identified using the MSE, helped guide clinical decisions and classify patients as being well or poorly adjusted to their circumstances. The signs and symptoms on which the NDs were based consisted of alterations in the following psychological domains: affect and mood, attention, behavior, conscience, intelligence, language, memory, orientation, thought, and sensory perception (Heldt, Marini, & Tomé, 2011). Data were collected from electronic patient records immediately after the appointment. A protocol was developed to standardize the collection of data on sociodemographic variables, clinical comorbidities, diagnoses, and nursing interventions. Continuous variables were described as mean and standard deviation (SD), while categorical variables were expressed as relative and absolute frequencies. Chi-square and Student’s t tests were used to verify the association between nursing interventions and NDs. The significance 169
Mental Health Nursing and Taxonomies
E. S. Thomé et al.
Table 1. Nursing Diagnoses and Respective Domains According to NANDA-I Domain Health promotion
Nursing diagnoses (code) Ineffective health maintenance (00099) Ineffective self-health management (00078)a Imbalanced nutrition: more than body requirements (00001) Risk for unstable blood glucose level (00179) Disturbed sleep pattern (00198) Disturbed sensory perception (visual) (00122)c Disturbed thought processd Hopelessness (00124) Chronic low self-esteem (00119) Impaired social interaction (00052)a Anxiety (00146)a Ineffective coping (00069) Impaired skin integrity (00044) Chronic pain (00133)
Nutrition Activity/rest Perception/cognition Self-perception Role relationships Coping/stress tolerance Safety/protection Comfort
n (%)b 2 (5) 11 (27) 2 (5) 1 (2) 2 (5) 1 (2) 2 (5) 5 (12) 3 (7) 16 (40) 14 (35) 1 (2) 1 (2) 2 (5)
a
Most frequent diagnoses. Frequency with which NDs in each domain were detected during outpatient visits. c Diagnosis removed from NANDA-I 2012–2014. d Diagnosis removed from NANDA-I 2009–2011. ND, nursing diagnosis. b
level was set to p < .05. Data were analyzed using the Statistical Package for Social Sciences (SPSS) software, version 18.0 (SPSS, Inc., Chicago, IL, USA). This research was approved by the research ethics committee of the Porto Alegre Clinical Hospital (HCPA) under protocol number 08-305. Findings Twenty six (65%) of the patients who attended mental health nursing appointments during the study had graduated middle school, while 14 (35%) had also finished high school. Most patients (n = 28; 70%) regularly used medication. Antidepressants were the most frequently reported drugs (n = 21; 52%). A number of patients also had additional medical diagnoses (n = 36; 90%), of which the most frequent were type 2 diabetes mellitus (n = 22; 55%) and systemic arterial hypertension (n = 20; 50%). Of the nine (22%) patients with mental disorders, six (15%) had been diagnosed with depression, two (5%) with schizophrenia, and one (2%) with generalized anxiety disorder. A total of 14 NDs were identified, with a mean of 1.5 diagnoses per patient (SD = 0.55; minimum of 1, maximum of 3) and a total of 63 diagnostic statements. The most frequently made NDs were impaired social interaction (00052) (n = 16; 40%), anxiety (00146) (n = 14; 35%), and ineffective self-health management (00078) (n = 11, 27%). The most frequently impaired domains were role relationships (n = 16; 40%), coping/stress tolerance (n = 15; 37%), and health promotion (n = 13; 32%) (see Table 1). The nursing interventions conducted and the diagnoses for which they were prescribed are displayed in Table 2. The most frequently prescribed interventions were socialization enhancement (5100), self-care assistance (1800), and exercise promotion (0200). 170
The results of analyses of the relationship between nursing interventions and the most frequent NDs are displayed on Table 3. Significant associations were found between the socialization enhancement (5100) and nutrition management (5246) interventions with the impaired social interaction (00052) (p < .001) and ineffective selfhealth management (00078) (p = .039) diagnoses, respectively. No significant associations were found between other NDs and interventions (p > .05).
Discussion and Implications The present results demonstrated that the NANDA-I and NIC taxonomies are applicable to outpatient mental health nursing appointments. The NCS in outpatient appointments contributed significantly to clinical interventions. The most frequent ND—impaired social interaction—was associated with socialization enhancement interventions and was found to be highly prevalent in the mental health setting. These findings are in agreement with a recently published review, which reported that the frequency of the impaired social interaction diagnosis in mental health settings has been particularly high in the past 20 years (EscaladaHernández et al., 2013). Studies suggest that making decisions about interventions based on a thorough assessment of patient health is an important part of responsible patient care. The systematization of interventions contributes significantly to this process, as it allows for more efficient medical decision making and helps provide solutions to problems that may arise during patient care (Pereira, Stuchi, & Arreguy-Sena, 2010). Socialization enhancement interventions help patients develop or refine interpersonal skills, and assist patients in daily routine activities. Such interventions underscore the importance of studying health and disease
E. S. Thomé et al.
Mental Health Nursing and Taxonomies
Table 2. Nursing Interventions Prescribed for the Most Frequent Nursing Diagnoses (ND) Nursing intervention (code)a
Nursing diagnoses (code)
n (%)b
Impaired social interaction (00052)
16 (40) Behavior modification (4360) Behavior modification: social skills (4362) Exercise promotion (0200) Self-care assistance (1800) Self-concept enhancement (5390) Socialization enhancement (5100)
Anxiety (00146)
14 (35) Anxiety reduction (5820) Behavior modification: social skills (4362) Exercise promotion (0200) Facilitating the mourning process (5290) Improving the support system (5440) Nutrition management (5246) Self-care assistance (1800)
Ineffective self-health management (00078)
11 (27) Anxiety reduction (5820) Behavior modification (4360) Behavior modification: social skills (4362) Drug use prevention (4500) Exercise promotion (0200) Nutrition management (5246) Self-care assistance (1800) Self-esteem enhancement (5400)
a
According to the Nursing Interventions Classification (NIC, 2008). Frequency with which interventions for each ND were prescribed during outpatient visits.
b
Table 3. Association Between Nursing Interventions and the Most Frequent Nursing Diagnoses Nursing diagnoses Nursing intervention (code)
Impaired social interaction (00052)
Anxiety (00146)
Ineffective self-health management (00078)
Self-care assistance (1800) Socialization enhancement (5100) Exercise promotion (0200) Behavior modification: social skills (4362) Nutrition management (5246)
16 (40%) 5 (31) 8 (50)** 4 (25) 3 (18) —
14 (35%) 3 (21) 1 (7) 4 (29) 3 (21) 2 (14)
11 (27%) 2 (18) — 2 (18) 2 (18) 4 (36)*
Data presented as absolute frequencies and percentages (%). Fisher’s exact test. *p < .05; **p < .001.
from a biopsychosocial standpoint in mental health clinics (Dochterman & Bulechek, 2008). Ineffective self-health management (a component of the health promotion domain) was one of the most frequently made NDs in the present study and was found to be associated with nutrition management interventions. This intervention was not specifically designed for mental health patients, which shows that nursing practitioners must see patients in their totality. This diagnosis was also associated with the prescription of anxiety reduction interventions, which, on an interesting note, were not found to be associated with an ND of anxiety. These data support previously reported associations between anxiety and chronic diseases (Coelho et al., 2009), which were present in 90% of the sample, and the relationship between these conditions and ineffective self-health
management (Freitas et al., 2011; Morilla-Herrera, Morales-Asencio, Fernández-Gallego, Berroblanco-Cobos, & Delgado-Romero, 2011). As a whole, these findings support the idea that when a patient is assessed in his totality during a mental health nursing appointment, the interventions prescribed and the NDs made are likely to be related. Although a number of patients received a disturbed thought process ND, the prevalence of this diagnosis was not as high as has been reported in other publications over the past 20 years (Escalada-Hernández et al., 2013). This finding may be attributable to the distinct nature of outpatient samples. It is also important to note that the fact that this ND was removed from the NANDA-I 2012–2014 taxonomy (Herdman, 2012) limits the use of this classification system in mental health services. 171
Mental Health Nursing and Taxonomies The present results evidence the efficacy of the NCS in nursing appointments in outpatient health settings. These measures allow nurses to make NDs and to prescribe interventions other than hospital admittance. The use of classification systems is one way to enhance the accuracy the interpretations of patient cues, apply adequate interventions, and achieve positive outcomes through NCS (Marini & Chaves, 2011). Some of the limitations of the present study include the small sample size and the cross-sectional design, which prevented the assessment of the results of the interventions prescribed. However, to the authors’ knowledge, this is one of the first studies to investigate the applicability of the NANDA-I–NIC taxonomy to outpatient mental health settings. The present findings underscore the need for further research on the use of the NANDA-I classification system in mental health care. We suggest that future studies focus on (a) the Nursing Outcomes Classification system, (b) the incidence and prevalence of different NDs, (c) the accuracy of NDs, and (d) clinical content validity of these diagnoses. In this way, nursing care could be further systematized and more effectively applied to mental health outpatient settings. References Beteghelli, P., Toledo, V. P., Crepschi, J. L. B., & Duran, E. C. M. (2005). Nursing assistance systematization in a mental health clinic. Revista Eletrônica de Enfermagem, 7(3), 334–343. Caixeta, C. C., & Moreno, V. (2008). The nurse and the actions of mental health in basic health units. Revista Eletrônica de Enfermagem, 10(1), 179–188. Cianciarullo, T. I., Gualda, D. M. R., Melleiro, M. M., & Anakubi, M. I. (2005). Sistema de Assistência de Enfermagem: Evolução e tendências (System of nursing care: Evolution and trends) (3rd ed.). São Paulo, SP: Ícone. Coelho, F. M. C., Pinheiro, R. T., Horta, B. L., Magalhães, P. V. S., Garcias, C. M. M., & Silva, C. V. (2009). Common mental disorders and chronic noncommunicable diseases in adults: A population-based study. Cadernos de Saúde Pública, 25(1), 59–67. Dochterman, J. M., & Bulechek, G. M. (2008). Classificação das Intervenções de Enfermagem (Nursing Interventions Classification) (4th ed.). Porto Alegre, RS: Artmed.
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E. S. Thomé et al. Escalada-Hernández, P., Muñoz-Hermoso, P., & Marro-Larrañaga, I. (2013). Atención de enfermería a pacientes psiquiátricos NANDA-NIC-NOC: una revisión de la literatura. (Nursing care for psychiatric patients defined by NANDA-NIC-NOC terminology: A literature review) Revista ROL de Enfermería, 36(3), 14–25. Franzen, E., Scain, S. F., Záchia, A. S., Schmidt, M. L., Rabin, E. G., Rosa, N. G., & Heldt, E. (2012). Outpatient nursing consultation and nursing diagnoses related to demographic and clinical characteristics. Revista Gaúcha de Enfermagem, 33(3), 42–51. Frauenfelder, F., Müller-Staub, M., Needham, I., & Van-Achterberg, T. (2011). Nursing phenomena in inpatient psychiatry. Journal of Psychiatric and Mental Health Nursing, 18, 221–235. Freitas, R. W. J. F., Araújo, M. F. M., Marinho, N. B. P., Damasceno, M. M. C., Caetano, J. Á., & Galvão, M. T. G. (2011). Factors related to nursing diagnosis, ineffective self-health management, among diabetics. Acta Paulista de Enfermagem, 24(3), 365–372. Heldt, E., Marini, M., & Tomé, E. S. (2011). Diagnósticos de Enfermagem com Base em sinais e sintomas-saúde mental. In E. R. R. Silva & A. F. Lucena (Eds.), Diagnósticos de enfermagem com base em sinais e sintomas (Nursing diagnoses based on signs and symptoms) (pp. 301–319). Porto Alegre, RS: Artmed. Heldt, E., & Rodrigues, J. A. (2006). Enfermagem psiquiátrica ambulatorial (Ambulatory psychiatric nursing). In A. M. Tasca, B. R. L. Santos, L. M. G. Paskulin, & S. Záchia (Eds.), Cuidado ambulatorial: consulta de enfermagem e grupos (Ambulatory care: Nursing consultation and groups) (pp. 205–210). Rio de Janeiro: EPU. Herdman, T. H. (Ed.). (2010). Diagnósticos de enfermagem da NANDA: Definições e classificação – 2009/2011 (NANDA International. Nursing diagnoses: Definitions and classification – 2009/2011). Porto Alegre, RS: Artmed. Herdman, T. H. (Ed.). (2012). NANDA International. Nursing diagnoses: Definitions and classification, 2012–2014. Oxford: Wiley Blackwell. Laguna-Parras, J. M., Jerez-Rojas, M. R., García-Fernández, F. P., Carrasco-Rodríguez, M. D., & Nogales-Vargas-Machuca, I. (2013). Effectiveness of the “sleep enhancement” nursing intervention in hospitalized mental health patients. Journal of Advanced Nursing, 69(6), 1279–1288. Marini, M., & Chaves, E. H. B. (2011). Evaluation of the accuracy of nursing diagnoses in a Brazilian emergency service. International Journal of Nursing Terminologies and Classifications, 22(2), 56–67. Morilla-Herrera, J. C., Morales-Asencio, J. M., Fernández-Gallego, M. C., Berroblanco-Cobos, E., & Delgado-Romero, A. (2011). Utilidad y validez de un instrumento basado en indicadores de la Nursing Outcomes Classification como ayuda al diagnóstico de pacientes crónicos de atención primaria con gestión ineficiente de la salud propia (Utility and validity of indicators from the Nursing Outcomes Classification as a support tool for diagnosing ineffective self health management in patients with chronic conditions in primary health care). Anales del Sistema Sanitario de Navarra, 34(1), 51–61. Osinaga, V. L. M., Furegato, A. R. F., & Santos, J. L. F. (2007). Users of three psychiatric services: Profile and opinion. Revista Latino-Americana de Enfermagem, 15(1), 70–77. Pereira, J. C., Stuchi, R. G., & Arreguy-Sena, C. (2010). Nursing assistance systematization proposal by the NANDA/NIC/NOC taxonomies for the diagnosis of deficient knowledge. Cogitare Enfermagem, 15(1), 74–81.
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Applicability of the NANDA-I and Nursing Interventions Classification Taxonomies to Mental Health Nursing Practice Emi da Silva Thomé, RN, MSN, Renata Cardoso Centena, RN, Andressa da Silva Behenck, RN, Maiko Marini, RN, MSN, and Elizeth Heldt, RN, PhD Emi da Silva Thomé, RN, MSN, is an Assistant Nurse at the Porto Alegre Clinical Hospital, Porto Alegre, RS, Brazil, Renata Cardoso Centena, RN, is a Graduate of the School of Nursing, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil, Andressa da Silva Behenck, RN, is an Assistant Nurse at the Porto Alegre Clinical Hospital, Porto Alegre, RS, Brazil, and a Master’s Student at the School of Nursing, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil, Maiko Marini, RN, MSN, is an Assistant Nurse at the Municipal Health Department of Caxias do Sul, Caxias, RS, Brazil, and Elizeth Heldt, RN, PhD is an Adjunct Professor in the Graduate School of Nursing/UFRGS, Porto Alegre, Brazil.
Search terms: Mental health, nursing appointment, nursing care systematization, nursing diagnoses and intervention Descritores: Consulta de enfermagem, sistematização da assistência de enfermagem, diagnóstico e intervenções de enfermagem, saúde mental Author contact: [email protected], with a copy to the Editor: [email protected]
168
PURPOSE: To assess the applicability of the systematization of nursing care (NCS) to outpatient nursing appointments using the NANDA-I and Nursing Interventions Classification (NIC) taxonomies. METHODS: Data were collected from 40 patients who had appointments with a nurse who specialized in mental health. Nursing diagnoses (NDs) and interventions were classified using the NANDA-I and NIC taxonomies, respectively. FINDINGS: A total of 14 different NDs were detected (minimum of one and maximum of three per appointment). The most frequently made diagnoses were impaired social interaction (00052), anxiety (00146), and ineffective self-health management (00078). A total of 23 nursing interventions were prescribed (approximately two per appointment), of which the most frequent were socialization enhancement (5100), self-care assistance (1800), and exercise promotion (0200). Significant associations were found between the most frequently detected NDs and the most commonly prescribed interventions (p > .05). CONCLUSIONS: The NCS through the use of classification systems allows mental health nurses to better identify and assist poorly adjusted patients. IMPLICATIONS FOR NURSING PRACTICE: The assessment of the applicability of the NCS to different areas of health care and types of medical assistance contributes significantly to the quality of nursing care. OBJETIVO: verificar a aplicabilidade da Sistematização da Assistência de Enfermagem (SAE) em consulta de enfermagem de saúde mental ambulatorial utilizando as taxonomias NANDA-I e NOC. MÉTODO: Os dados foram obtidos de 40 pacientes que consultaram com enfermeira especialista do programa de enfermagem em saúde mental. Os NDs e as intervenções foram definidos com base nas taxonomias da NANDA-I e da NIC, respectivamente. RESULTADOS: Foram identificados 14 diagnósticos de enfermagem (DE) diferentes (mínimo de 1 e máximo de 3 por consulta) e os mais frequentes foram: interação social prejudicada (00052), ansiedade (00146) e autocontrole ineficaz da saúde. Dentre as intervenções de enfermagem foram identificadas 23 (aproximadamente 2 por consulta) e as mais frequentes foram: aumento da socialização (5100) e assistência no autocuidado (1800). Foi verificada associação significativa entre os ND e as intervenções mais frequentes (p < .05). CONCLUSÕES: A SAE em consulta de enfermagem de saúde mental ambulatorial possibilita identificar as respostas desadaptadas e determinar as intervenções prioritárias. IMPLICAÇÕES PARA A PRÁTICA EM ENFERMAGEM: Avaliar a aplicabilidade da SAE em diferentes especialidades e em diferentes modalidades de atendimento contribui para a qualificação do cuidado em enfermagem. © 2014 NANDA International, Inc. International Journal of Nursing Knowledge Volume 25, No. 3, October 2014
E. S. Thomé et al. Outpatient clinics play an important role in providing multidisciplinary services to nonhospitalized patients. Over recent years, these services have been made increasingly available in an attempt to reduce hospital admission rates and increase the efficacy of preventive and health promotion programs. However, studies suggest that nurse practitioners at these services have been unable to meet patient demand (Osinaga, Furegato, & Santos, 2007), especially in cases of mental illness, which are highly prevalent and insufficiently addressed by health services (Caixeta & Moreno, 2008). In southern Brazil, university hospitals comprise an important part of the health system, as they are able to provide assistance to patients at different stages of treatment. Psychiatric wards are available for acute cases, psychosocial care centers (CAPS) provide rehabilitation services, and outpatient clinics assist with treatment maintenance through nursing appointments (Franzen et al., 2012). Outpatient nursing care is largely managed by the Mental Health Nursing Program, a specialized public health service developed to assist patients with mental disorders. The program targets patients with mental disorders or maladaptive functioning and their families, and assists them through nursing appointments whose main therapeutic tool is the nursing process itself (Heldt & Rodrigues, 2006). The operationalization of the nursing process was facilitated by the development of the NANDA-I taxonomy for coding nursing diagnoses (NDs) (Herdman, 2010) and the Nursing Interventions Classification (NIC) (Dochterman & Bulechek, 2008), which, together, led to the systematization of nursing care (NCS). Mental health nursing interventions based on NDs may be implemented so as to prevent or treat diseases, or for health promotion purposes. The NIC taxonomy is based on group nursing interventions to improve health outcomes (Dochterman & Bulechek, 2008). In outpatient health visits, interventions to improve coping skills are developed with the patient through goal setting and agreements (Heldt & Rodrigues, 2006). In the context of these interventions, the implementation of a diagnostic system in clinical practice allows nurses to identify with greater clarity the patient care needs for which they are responsible (Cianciarullo, Gualda, Melleiro, & Anakubi, 2005). A number of studies have assessed the applicability of the NANDA-I and NIC taxonomies to mental health settings (Frauenfelder, Müller-Staub, Needham, & Van-Achterberg, 2011; Laguna-Parras, Jerez-Rojas, GarcíaFernández, Carrasco-Rodríguez, & Nogales-VargasMachuca, 2013). However, most of these studies were conducted with inpatient populations, which are quite distinct from outpatient samples. The fundamental difference between these two settings is the duration of the interaction between the nurse and the patient, which is approximately 24 hr in inpatient settings but only 40 min, on average, in outpatient settings. The stages of patient care also differ between these two settings. While for inpatients the focus of medical interventions is mostly on acute signs and symptoms, outpatient treatments focus on the
Mental Health Nursing and Taxonomies maintenance of well-being and health promotion (Franzen et al., 2012). A study of outpatient mental health care found that the NCS improves the efficacy of nursing appointments, as it allows the nurse to know and work with the patient, his family, and the community, as well as to promote and maintain health (Beteghelli, Toledo, Crepschi, & Duran, 2005). However, the study was qualitative and focused only on the description of the most frequent diagnoses. A recent review of the NANDA-I–NIC taxonomies in mental health noted the scarcity of publications on the use of these taxonomies in mental health settings. Of the articles included in this review, 10 examined the frequency of different NANDA-I and/or NIC diagnoses, and 4 assessed care plans. The authors of this study also discussed the lack of studies in this area (Escalada-Hernández, MuñozHermoso, & Marro-Larrañaga, 2013). Therefore, to address this gap in the literature, the present study sought to assess the applicability of the NCS to outpatient nursing appointments using the NANDA-I and NIC taxonomies. Methods This cross-sectional study was performed in a university hospital, which, in addition to providing medical services, was involved in teaching and research activities. The participating patients were referred from other health units due to maladaptive responses to stress or psychiatric diagnoses (Heldt & Rodrigues, 2006). The sample consisted of 40 consecutive patients who attended nursing appointments between February and March 2010. All participants were over 18 years old. Appointments lasted an average of 40 min and were conducted by a nurse who specialized in mental health. The NDs and interventions were classified using the NANDA-I and NIC taxonomies, respectively. During the appointment, nurses performed a mental state examination (MSE), an anamnesis, and a physical examination on each patient (Franzen et al., 2012; Heldt & Rodrigues, 2006). The alterations in psychological functioning, as well as the signs and symptoms identified using the MSE, helped guide clinical decisions and classify patients as being well or poorly adjusted to their circumstances. The signs and symptoms on which the NDs were based consisted of alterations in the following psychological domains: affect and mood, attention, behavior, conscience, intelligence, language, memory, orientation, thought, and sensory perception (Heldt, Marini, & Tomé, 2011). Data were collected from electronic patient records immediately after the appointment. A protocol was developed to standardize the collection of data on sociodemographic variables, clinical comorbidities, diagnoses, and nursing interventions. Continuous variables were described as mean and standard deviation (SD), while categorical variables were expressed as relative and absolute frequencies. Chi-square and Student’s t tests were used to verify the association between nursing interventions and NDs. The significance 169
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E. S. Thomé et al.
Table 1. Nursing Diagnoses and Respective Domains According to NANDA-I Domain Health promotion
Nursing diagnoses (code) Ineffective health maintenance (00099) Ineffective self-health management (00078)a Imbalanced nutrition: more than body requirements (00001) Risk for unstable blood glucose level (00179) Disturbed sleep pattern (00198) Disturbed sensory perception (visual) (00122)c Disturbed thought processd Hopelessness (00124) Chronic low self-esteem (00119) Impaired social interaction (00052)a Anxiety (00146)a Ineffective coping (00069) Impaired skin integrity (00044) Chronic pain (00133)
Nutrition Activity/rest Perception/cognition Self-perception Role relationships Coping/stress tolerance Safety/protection Comfort
n (%)b 2 (5) 11 (27) 2 (5) 1 (2) 2 (5) 1 (2) 2 (5) 5 (12) 3 (7) 16 (40) 14 (35) 1 (2) 1 (2) 2 (5)
a
Most frequent diagnoses. Frequency with which NDs in each domain were detected during outpatient visits. c Diagnosis removed from NANDA-I 2012–2014. d Diagnosis removed from NANDA-I 2009–2011. ND, nursing diagnosis. b
level was set to p < .05. Data were analyzed using the Statistical Package for Social Sciences (SPSS) software, version 18.0 (SPSS, Inc., Chicago, IL, USA). This research was approved by the research ethics committee of the Porto Alegre Clinical Hospital (HCPA) under protocol number 08-305. Findings Twenty six (65%) of the patients who attended mental health nursing appointments during the study had graduated middle school, while 14 (35%) had also finished high school. Most patients (n = 28; 70%) regularly used medication. Antidepressants were the most frequently reported drugs (n = 21; 52%). A number of patients also had additional medical diagnoses (n = 36; 90%), of which the most frequent were type 2 diabetes mellitus (n = 22; 55%) and systemic arterial hypertension (n = 20; 50%). Of the nine (22%) patients with mental disorders, six (15%) had been diagnosed with depression, two (5%) with schizophrenia, and one (2%) with generalized anxiety disorder. A total of 14 NDs were identified, with a mean of 1.5 diagnoses per patient (SD = 0.55; minimum of 1, maximum of 3) and a total of 63 diagnostic statements. The most frequently made NDs were impaired social interaction (00052) (n = 16; 40%), anxiety (00146) (n = 14; 35%), and ineffective self-health management (00078) (n = 11, 27%). The most frequently impaired domains were role relationships (n = 16; 40%), coping/stress tolerance (n = 15; 37%), and health promotion (n = 13; 32%) (see Table 1). The nursing interventions conducted and the diagnoses for which they were prescribed are displayed in Table 2. The most frequently prescribed interventions were socialization enhancement (5100), self-care assistance (1800), and exercise promotion (0200). 170
The results of analyses of the relationship between nursing interventions and the most frequent NDs are displayed on Table 3. Significant associations were found between the socialization enhancement (5100) and nutrition management (5246) interventions with the impaired social interaction (00052) (p < .001) and ineffective selfhealth management (00078) (p = .039) diagnoses, respectively. No significant associations were found between other NDs and interventions (p > .05).
Discussion and Implications The present results demonstrated that the NANDA-I and NIC taxonomies are applicable to outpatient mental health nursing appointments. The NCS in outpatient appointments contributed significantly to clinical interventions. The most frequent ND—impaired social interaction—was associated with socialization enhancement interventions and was found to be highly prevalent in the mental health setting. These findings are in agreement with a recently published review, which reported that the frequency of the impaired social interaction diagnosis in mental health settings has been particularly high in the past 20 years (EscaladaHernández et al., 2013). Studies suggest that making decisions about interventions based on a thorough assessment of patient health is an important part of responsible patient care. The systematization of interventions contributes significantly to this process, as it allows for more efficient medical decision making and helps provide solutions to problems that may arise during patient care (Pereira, Stuchi, & Arreguy-Sena, 2010). Socialization enhancement interventions help patients develop or refine interpersonal skills, and assist patients in daily routine activities. Such interventions underscore the importance of studying health and disease
E. S. Thomé et al.
Mental Health Nursing and Taxonomies
Table 2. Nursing Interventions Prescribed for the Most Frequent Nursing Diagnoses (ND) Nursing intervention (code)a
Nursing diagnoses (code)
n (%)b
Impaired social interaction (00052)
16 (40) Behavior modification (4360) Behavior modification: social skills (4362) Exercise promotion (0200) Self-care assistance (1800) Self-concept enhancement (5390) Socialization enhancement (5100)
Anxiety (00146)
14 (35) Anxiety reduction (5820) Behavior modification: social skills (4362) Exercise promotion (0200) Facilitating the mourning process (5290) Improving the support system (5440) Nutrition management (5246) Self-care assistance (1800)
Ineffective self-health management (00078)
11 (27) Anxiety reduction (5820) Behavior modification (4360) Behavior modification: social skills (4362) Drug use prevention (4500) Exercise promotion (0200) Nutrition management (5246) Self-care assistance (1800) Self-esteem enhancement (5400)
a
According to the Nursing Interventions Classification (NIC, 2008). Frequency with which interventions for each ND were prescribed during outpatient visits.
b
Table 3. Association Between Nursing Interventions and the Most Frequent Nursing Diagnoses Nursing diagnoses Nursing intervention (code)
Impaired social interaction (00052)
Anxiety (00146)
Ineffective self-health management (00078)
Self-care assistance (1800) Socialization enhancement (5100) Exercise promotion (0200) Behavior modification: social skills (4362) Nutrition management (5246)
16 (40%) 5 (31) 8 (50)** 4 (25) 3 (18) —
14 (35%) 3 (21) 1 (7) 4 (29) 3 (21) 2 (14)
11 (27%) 2 (18) — 2 (18) 2 (18) 4 (36)*
Data presented as absolute frequencies and percentages (%). Fisher’s exact test. *p < .05; **p < .001.
from a biopsychosocial standpoint in mental health clinics (Dochterman & Bulechek, 2008). Ineffective self-health management (a component of the health promotion domain) was one of the most frequently made NDs in the present study and was found to be associated with nutrition management interventions. This intervention was not specifically designed for mental health patients, which shows that nursing practitioners must see patients in their totality. This diagnosis was also associated with the prescription of anxiety reduction interventions, which, on an interesting note, were not found to be associated with an ND of anxiety. These data support previously reported associations between anxiety and chronic diseases (Coelho et al., 2009), which were present in 90% of the sample, and the relationship between these conditions and ineffective self-health
management (Freitas et al., 2011; Morilla-Herrera, Morales-Asencio, Fernández-Gallego, Berroblanco-Cobos, & Delgado-Romero, 2011). As a whole, these findings support the idea that when a patient is assessed in his totality during a mental health nursing appointment, the interventions prescribed and the NDs made are likely to be related. Although a number of patients received a disturbed thought process ND, the prevalence of this diagnosis was not as high as has been reported in other publications over the past 20 years (Escalada-Hernández et al., 2013). This finding may be attributable to the distinct nature of outpatient samples. It is also important to note that the fact that this ND was removed from the NANDA-I 2012–2014 taxonomy (Herdman, 2012) limits the use of this classification system in mental health services. 171
Mental Health Nursing and Taxonomies The present results evidence the efficacy of the NCS in nursing appointments in outpatient health settings. These measures allow nurses to make NDs and to prescribe interventions other than hospital admittance. The use of classification systems is one way to enhance the accuracy the interpretations of patient cues, apply adequate interventions, and achieve positive outcomes through NCS (Marini & Chaves, 2011). Some of the limitations of the present study include the small sample size and the cross-sectional design, which prevented the assessment of the results of the interventions prescribed. However, to the authors’ knowledge, this is one of the first studies to investigate the applicability of the NANDA-I–NIC taxonomy to outpatient mental health settings. The present findings underscore the need for further research on the use of the NANDA-I classification system in mental health care. We suggest that future studies focus on (a) the Nursing Outcomes Classification system, (b) the incidence and prevalence of different NDs, (c) the accuracy of NDs, and (d) clinical content validity of these diagnoses. In this way, nursing care could be further systematized and more effectively applied to mental health outpatient settings. References Beteghelli, P., Toledo, V. P., Crepschi, J. L. B., & Duran, E. C. M. (2005). Nursing assistance systematization in a mental health clinic. Revista Eletrônica de Enfermagem, 7(3), 334–343. Caixeta, C. C., & Moreno, V. (2008). The nurse and the actions of mental health in basic health units. Revista Eletrônica de Enfermagem, 10(1), 179–188. Cianciarullo, T. I., Gualda, D. M. R., Melleiro, M. M., & Anakubi, M. I. (2005). Sistema de Assistência de Enfermagem: Evolução e tendências (System of nursing care: Evolution and trends) (3rd ed.). São Paulo, SP: Ícone. Coelho, F. M. C., Pinheiro, R. T., Horta, B. L., Magalhães, P. V. S., Garcias, C. M. M., & Silva, C. V. (2009). Common mental disorders and chronic noncommunicable diseases in adults: A population-based study. Cadernos de Saúde Pública, 25(1), 59–67. Dochterman, J. M., & Bulechek, G. M. (2008). Classificação das Intervenções de Enfermagem (Nursing Interventions Classification) (4th ed.). Porto Alegre, RS: Artmed.
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E. S. Thomé et al. Escalada-Hernández, P., Muñoz-Hermoso, P., & Marro-Larrañaga, I. (2013). Atención de enfermería a pacientes psiquiátricos NANDA-NIC-NOC: una revisión de la literatura. (Nursing care for psychiatric patients defined by NANDA-NIC-NOC terminology: A literature review) Revista ROL de Enfermería, 36(3), 14–25. Franzen, E., Scain, S. F., Záchia, A. S., Schmidt, M. L., Rabin, E. G., Rosa, N. G., & Heldt, E. (2012). Outpatient nursing consultation and nursing diagnoses related to demographic and clinical characteristics. Revista Gaúcha de Enfermagem, 33(3), 42–51. Frauenfelder, F., Müller-Staub, M., Needham, I., & Van-Achterberg, T. (2011). Nursing phenomena in inpatient psychiatry. Journal of Psychiatric and Mental Health Nursing, 18, 221–235. Freitas, R. W. J. F., Araújo, M. F. M., Marinho, N. B. P., Damasceno, M. M. C., Caetano, J. Á., & Galvão, M. T. G. (2011). Factors related to nursing diagnosis, ineffective self-health management, among diabetics. Acta Paulista de Enfermagem, 24(3), 365–372. Heldt, E., Marini, M., & Tomé, E. S. (2011). Diagnósticos de Enfermagem com Base em sinais e sintomas-saúde mental. In E. R. R. Silva & A. F. Lucena (Eds.), Diagnósticos de enfermagem com base em sinais e sintomas (Nursing diagnoses based on signs and symptoms) (pp. 301–319). Porto Alegre, RS: Artmed. Heldt, E., & Rodrigues, J. A. (2006). Enfermagem psiquiátrica ambulatorial (Ambulatory psychiatric nursing). In A. M. Tasca, B. R. L. Santos, L. M. G. Paskulin, & S. Záchia (Eds.), Cuidado ambulatorial: consulta de enfermagem e grupos (Ambulatory care: Nursing consultation and groups) (pp. 205–210). Rio de Janeiro: EPU. Herdman, T. H. (Ed.). (2010). Diagnósticos de enfermagem da NANDA: Definições e classificação – 2009/2011 (NANDA International. Nursing diagnoses: Definitions and classification – 2009/2011). Porto Alegre, RS: Artmed. Herdman, T. H. (Ed.). (2012). NANDA International. Nursing diagnoses: Definitions and classification, 2012–2014. Oxford: Wiley Blackwell. Laguna-Parras, J. M., Jerez-Rojas, M. R., García-Fernández, F. P., Carrasco-Rodríguez, M. D., & Nogales-Vargas-Machuca, I. (2013). Effectiveness of the “sleep enhancement” nursing intervention in hospitalized mental health patients. Journal of Advanced Nursing, 69(6), 1279–1288. Marini, M., & Chaves, E. H. B. (2011). Evaluation of the accuracy of nursing diagnoses in a Brazilian emergency service. International Journal of Nursing Terminologies and Classifications, 22(2), 56–67. Morilla-Herrera, J. C., Morales-Asencio, J. M., Fernández-Gallego, M. C., Berroblanco-Cobos, E., & Delgado-Romero, A. (2011). Utilidad y validez de un instrumento basado en indicadores de la Nursing Outcomes Classification como ayuda al diagnóstico de pacientes crónicos de atención primaria con gestión ineficiente de la salud propia (Utility and validity of indicators from the Nursing Outcomes Classification as a support tool for diagnosing ineffective self health management in patients with chronic conditions in primary health care). Anales del Sistema Sanitario de Navarra, 34(1), 51–61. Osinaga, V. L. M., Furegato, A. R. F., & Santos, J. L. F. (2007). Users of three psychiatric services: Profile and opinion. Revista Latino-Americana de Enfermagem, 15(1), 70–77. Pereira, J. C., Stuchi, R. G., & Arreguy-Sena, C. (2010). Nursing assistance systematization proposal by the NANDA/NIC/NOC taxonomies for the diagnosis of deficient knowledge. Cogitare Enfermagem, 15(1), 74–81.
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