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Journal of clinical nursing v.26 no.3/4, 2017년, pp.379 - 387   SCIE SSCI
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Advanced Nursing Process quality: Comparing the International Classification for Nursing Practice (ICNP) with the NANDA‐International (NANDA‐I) and Nursing Interventions Classification (NIC)

Rabelo‐Silva, Eneida Rejane (Graduate Program in Nursing at Federal University of Rio Grande do Sul and Hospital de Clínicas de Porto Alegre and Grupo de Estudo e Pesquisa em Enfermagem no Cuidado ao Adulto e Idoso (GEPECADI), Porto Alegre, RS, Brazil ) ; Dantas Cavalcanti, Ana Carla (Universidade Federal Fluminense, Niterói, RJ, Brazil ) ; Ramos Goulart Caldas, Maria Cristina (Nurse of Instituto Nacional do Câncer (HC III), Rio de Janeiro, RJ, Brazil ) ; Lucena, Amália de Fátima (Graduate Program in Nursing at Federal University of Rio Grande do Sul and Hospital de Clínicas de Porto Alegre and Grupo de Estudo e Pesquisa em Enfermagem no Cuidado ao Adulto e Idoso (GEPECADI), Porto Alegre, RS, Brazil ) ; Almeida, Miriam de Abreu (Graduate Program in Nursing at Federal University of Rio Grande do Sul and Hospital de Clínicas de Porto Alegre and Grupo de Estudo e Pesquisa em Enfermagem no Cuidado ao Adulto e Idoso (GEPECADI), Porto Alegre, RS, Brazil ) ; Linch, Graciele Fernanda da Costa ; da Silva, Marcos Barragan ; Müller‐Staub, Maria ;
  • 초록  

    Aims and objectives To assess the quality of the advanced nursing process in nursing documentation in two hospitals. Background Various standardised terminologies are employed by nurses worldwide, whether for teaching, research or patient care. These systems can improve the quality of nursing records, enable care continuity, consistency in written communication and enhance safety for patients and providers alike. Design Cross‐sectional study. Methods A total of 138 records from two facilities (69 records from each facility) were analysed, one using the NANDA‐International and Nursing Interventions Classification terminology (Centre 1) and one the International Classification for Nursing Practice (Centre 2), by means of the Quality of Diagnoses, Interventions, and Outcomes instrument. Quality of Diagnoses, Interventions, and Outcomes scores range from 0–58 points. Nursing records were dated 2012–2013 for Centre 1 and 2010–2011 for Centre 2. Results Centre 1 had a Quality of Diagnoses, Interventions, and Outcomes score of 35·46 (±6·45), whereas Centre 2 had a Quality of Diagnoses, Interventions, and Outcomes score of 31·72 (±4·62) ( p Conclusion The quality of nursing documentation was superior at Centre 1, although both facilities demonstrated moderate scores considering the maximum potential score of 58 points. Reliability analyses showed satisfactory results for both standardised terminologies. Relevance to clinical practice Nursing leaders should use a validated instrument to investigate the quality of nursing records after implementation of standardised terminologies.


  • 주제어

    classification .   International Classification for Nursing Practice .   NANDA‐International .   Nursing Interventions Classification .   nursing process .   nursing records .   Quality of Diagnoses, Interventions, and Outcomes instrument.  

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