Methodological approach for the development of terminology subsets ICNP®: an integrative review

Recorrido metodológico para la confección de subconjuntos terminológicos CIPE®: revisión integradora

Abstracts

Objective

To analyze the methodological aspects used for the preparation of terminology subsets of the International Classification for Nursing Practice (ICNP®), in dissertations and theses in the Brazilian nursing.

Method

This is an integrative review of the Brazilian dissertations and theses defended in the period from 2007 to 2013, which were included seven dissertations.

Results

The increasing production of studies on the theme by Brazilian nurses shows a concern for a unified language for the profession. However, the results demonstrate the lack of uniformity in the conduct of studies, especially in relation to the stages of content validation. The initiatives of some authors to systematize alternative methods for creating these subsets also stood out.

Conclusion

We suggest the development of new terminology subsets, following standards of methodological rigor, as well as its application and validation by the selected clientele, to ensure greater reliability of results and desired changes for the profession.

Nursing; Nursing research; Classification; Terminology; Review

Objetivo

Analizar los aspectos metodológicos utilizados para la elaboración de subconjuntos terminológicos de la Clasificación Internacional para la Práctica de Enfermería (CIPE®), en tesis de máster o doctorado de la Enfermería brasileña.

Método

Revisión integradora de las tesis de máster y doctorado brasileñas defendidas en el período comprendido entre 2007 y 2013, de las cuales fueron incluidas siete tesis de máster.

Resultados

La producción creciente de estudios acerca de la temática por los enfermeros brasileños evidencia una preocupación por un lenguaje unificado para la profesión. Sin embargo, los resultados demuestran la ausencia de uniformidad en cuanto a la conducción de los estudios, especialmente con respecto a las etapas de validación de contenido. Se destacaron también las iniciativas de algunos autores de sistematizar métodos alternativos para la confección de dichos subconjuntos.

Conclusión

Se sugiere el desarrollo de nuevos subconjuntos terminológicos, siguiendo estándares de rigor metodológico, así como su aplicación y validación junto a la clientela seleccionada, a fin de asegurar una mayor confiabilidad de los resultados y los cambios anhelados para la profesión.


Enfermería; Investigación en enfermeira; Clasificación; Terminología; Revisión

Objetivo

Analisar os aspectos metodológicos utilizados para a elaboração de subconjuntos terminológicos da Classificação Internacional para a Prática de Enfermagem (CIPE®), em dissertações e teses da Enfermagem brasileira.

Método

Revisão integrativa das dissertações e teses brasileiras defendidas no período compreendido entre 2007 e 2013, das quais foram incluídas sete dissertações.

Resultados

A produção crescente de estudos acerca da temática pelos enfermeiros brasileiros evidencia uma preocupação por uma linguagem unificada para a profissão. Contudo, os resultados demonstram a ausência de uniformidade quanto à condução dos estudos, principalmente em relação às etapas de validação de conteúdo. Destacaram-se, também, as iniciativas de alguns autores para a sistematização de métodos alternativos para a confecção desses subconjuntos.

Conclusão

Sugere-se o desenvolvimento de novos subconjuntos terminológicos, seguindo padrões de rigor metodológico, como também sua aplicação e validação junto à clientela selecionada, a fim de garantir maior confiabilidade dos resultados e as mudanças almejadas para a profissão.



Enfermagem; Pesquisa em enfermagem
; Classificação; Terminologia; Revisão

Introduction

Currently, the need for a proper language to define and describe the professional practice of nursing has appeared as subject of debates and evoked efforts of nurses from around the world in search of the scientific development of the profession and the strengthening of their clinical practice in the different contexts of care(¹).

Aimed at unifying the language of Nursing, several classification systems for the phenomena of clinical practice were developed. Among these systems, the International Classification for Nursing Practice (ICNP®) gathers in the same classification, the diagnostic terms and concepts, as well as the nursing outcomes and interventions. Thus, it represents an important information instrument for describing the elements of clinical practice, promoting change through education, administration and research, and providing data that identify the contribution of nursing in health care. Its use results in greater visibility and professional recognition, promoting more autonomy for the profession(²-³).

Therefore, the ICNP® is a technology that facilitates the organization of clinical nursing care and the scientific, technological and innovative advance of the profession by enabling the development of terminology subsets targeted to specific areas of clinical practice. Such terminology subsets (or catalogs) consist of a set of statements of diagnoses, outcomes and interventions in nursing that favor the adoption of a unified and accessible language to nurses worldwide, as recommended by the International Council of Nurses (ICN)(⁴).

The ICN encourages the participation of nurses from around the world in the development of terminology subsets as a strategy to unify the language of Nursing and identify, explain and evaluate the elements that describe its clinical practice(⁵). However, the development of an ICNP® terminology subset requires careful attention, accuracy and experience of the researchers involved. It is also recommended that the standards of methodological rigor are followed in order to avoid losing important data and ensure the quality of the final product of the research.

In this context, emerged the question about the existence of a uniform methodological process used by researchers to elaborate terminology subsets or catalogs using ICNP®.

Faced with the need to follow high standards of methodological rigor for a successful process of developing these subsets, it is believed that the construction of an overview of the methodological approaches used can provide an important help resource for nurses and researchers choosing the best strategies for structuring terminology subsets, ensuring their greater quality and reliability.

The aim of the present study was to analyze the methodological aspects used for the development of ICNP® terminology subsets in Brazilian Nursing dissertations and thesis.

Method

This is an integrative review of the Brazilian dissertations and theses on the process of developing ICNP® terminology subsets for the nursing clinical practice. This method allows investigating a topic by summarizing the research carried out in order to obtain further conclusions based on the critical evaluation of different methodological approaches. The steps of this review were: identification of the subject; formulation of a research question; search and selection of the literature; categorization, assessment of studies and presentation of the review(⁶-⁷).

The following question was formulated to guide the integrative review: What is the methodological approach used for the development of ICNP® terminology subsets described in Brazilian nursing dissertations and theses?

The search for publications occurred between the months of August and October 2013 in three ways: access to the electronic catalog of dissertations and theses of the Center for Studies and Research in Nursing (CEPEn); online access to the database of Theses of the Coordination of Improvement of Higher Education Personnel (CAPES) and the Brazilian Digital Library of Theses and Dissertations (BDTD); access to the electronic pages of the stricto sensu post-graduate programs that have a partnership with the Centre for Research and Development of the Brazilian ICNP®, which are: Post-Graduate Program in Nursing of the Federal University of Paraíba, Post-Graduate Program in Nursing of the Federal University of Bahia, Post-Graduate Program in Nursing of the Federal University of Goiás, Post-Graduate Program in Sciences of Care in Health of the Fluminense Federal University, Post-Graduate Program in Clinical Care in Nursing of the State University of Ceará, Post-Graduate Program in Nursing of the University of São Paulo(⁸).

It focused on articles published between 2007 and 2013, considering that in 2007 a method for the development of terminology subsets was internationally published(⁹). The choice was to research information on theses and dissertations, given their greater detail regarding the methodological steps taken.

The survey of the studies in the catalog of CEPEn occurred initially by reading the titles and abstracts of dissertations and theses. The search on virtual libraries was through the following keywords: nursing, classification, vocabulary, terminology, nursing process, nursing diagnoses, nursing interventions and nursing outcomes. On the websites of the post-graduate programs were sought dissertations and theses from the year 2007.

The methodological studies on the development of ICNP® catalogs and terminology subsets published since the year 2007 were included in this review. The studies not electronically available in full were excluded.

The steps of extraction and analysis of the material were carried out by a single reviewer and consisted of careful evaluation through an exploratory reading of the complete studies and completion of the data collection instrument with the following items: identification number, bibliographic reference, educational institution linked to the research, academic modality, year of defense, methodological approach of development of the subset, main results and relevant contributions/aspects of the development of the subset for the nursing clinical practice.

The model proposed by Coenen and Kim was used as theoretical framework for the analysis of data relating to the methodological approach of development of the ICNP® terminology subset(⁴), which consists of six steps that are correlated to the three main components of the life cycle of this terminology, namely: Development and research (identification of clients and health priority and collection of relevant terms and concepts for the health priority); Operation and maintenance (mapping of concepts identified by the ICNP® terminology and modeling of new concepts) and Dissemination and education (finalization and publication of the catalog).

It is worth noting that the curricular analysis of each investigated author was done by searching the Lattes Platform, in the web page of the National Council for Scientific and Technological Development (CNPq - Conselho Nacional de Desenvolvimento Científico e Tecnológico) in order to collect relevant data to complement the results of this review.

The results were presented in the form of tables, discussed in the light of the adopted theoretical framework and the literature relevant to the topic.

Results

In total, were identified 304 references, of which 285 were excluded for not presenting a methodology for the development of a terminology subset, and one for not being electronically available in full. After reading the titles and abstracts, were excluded 11 articles that were repeated in more than one of the investigated sources. Thus, seven studies were included in this integrative review, which was entirely composed by master dissertations (Chart 1).

Chart 1
Distribution of the studies found and selected - Fortaleza, 2013

• Note: CEPEn: Center for Studies and Research in Nursing; CAPES: Coordination of Improvement of Higher Education Personnel; BDTD: Brazilian Digital Library of Theses and Dissertations.

Chart 2 shows the data identifying the dissertations: author, title, institution and year of defense. Note that among the total number of publications analyzed, five were produced in the Northeast region of Brazil, more specifically in the Post-Graduate Program in Nursing of the Federal University of Paraíba; and two in the Southeast region, in the Course of Professional Master in Nursing Care of the Aurora Afonso Costa Nursing School, Fluminense Federal University. As for the year, the dissertations were defended from 2009, maintaining a constancy in the number of studies produced during the investigated period.

Chart 2
Data identifying the dissertations analyzed - Fortaleza, 2013

Chart 3 shows the data regarding the methodological approach adopted by the researchers in the study, according to the Development and research component of the life cycle of the ICNP® terminology, in line with the theoretical framework adopted.

In the first stage (definition of the clientele and the health priority), several themes supported the development of terminology subsets: congestive heart failure (CHF), cancer pain, elderly, hypertensive patients, those with chronic renal failure (CRF), multiple myeloma and prostatectomy.

In the second step (collection of relevant terms for the selected health priority), many different techniques were used to obtain the data: research in electronic databases, conceptual analysis, analysis of research instruments, database of terms, textbooks and official documents published in the country. The content validation of the collected terms was accomplished by only three authors (D3, D5 and D7), and showed variations in relation to the selection criteria and the number of professionals who composed the committee of judges, ranging between two and 10 (Chart 3).

Chart 3
Data from the methodological approach adopted in the development of the subsets, according to the Development and research component of the ICNP® life cycle - Fortaleza, 2013

Chart 4 presents data regarding the methodological approach adopted in the dissertations included in this review according to the second component called Operation and maintenance of the ICNP® terminology life cycle.

Chart 4
Data from the methodological approach adopted in the development of the subsets, according to the second component Operation and maintenance of the ICNP® life cycle - Fortaleza, 2013

In the third stage, all the authors performed the cross mapping of terms and concepts collected in studies with ICNP® in its different versions. With respect to the fourth stage (modeling of new concepts), none of the authors made it clear if they did it.

The content validation of the statements of diagnoses, nursing interventions and outcomes was performed in four studies (D4, D5, D6 and D7), and the number of professionals who composed the committee of judges ranged from five to 15 nurse-teachers and/or care nurses with expertise in the subject area of the subset.

Chart 5 presents the two final stages of the development process of ICNP® terminology subsets, which are related to the Dissemination and education component of the life cycle of this terminology.

In the fifth stage (completion), there was predominance of the Theory of Basic Human Needs by Wanda Horta as the theoretical framework of choice for the structuring of terminology subsets proposed in the analyzed dissertations. A large number of statements of diagnoses/outcomes and nursing interventions were developed, ranging from 33-156 and 27-627, respectively (Chart 5).

Chart 5
Data from the methodological approach adopted in the development of the subsets, according to the Dissemination and education component of the ICNP® life cycle - Fortaleza, 2013

Regarding this step, it is noteworthy that D4 showed only statements of nursing diagnoses; D4 and D6 did not follow the format indicated in the literature for presenting the subset; and currently, D2 and D3 are in clinical validation process.

The sixth stage (dissemination) was performed by all authors through the publication of articles in journals and/or in the form of papers presented at scientific events.

Discussion

The scientific and technological production in the area or field of nursing knowledge has evolved due to the increase of stricto sensu post-graduate programs in number and in qualification, driven by incentive policies and funding, and by the need to consolidate Nursing as science, technology and social practice. This has propelled the production, dissemination and consumption of studies and technologies of impact that can help to transform and qualify the clinical practice(¹⁷).

In this context, the study and use of ICNP® stands out in the development of terminology subsets applicable to the professional practice as a relevant technological resource for the systematization and classification of the nursing clinical practice, through stricto sensu post-graduate programs.

The publication of the first studies produced in the Brazilian stricto sensu post-graduate programs about the development of these subsets from 2009 is justified by the fact that only in 2007 was released a method systematizing its development in an international event(⁷), culminating in the publication of the Guide for the Development of ICNP® Catalogs by the ICN in the following year(¹⁸).

The debate about the development of these subsets is recent, and the scientific production of post-graduate programs in nursing on this subject demonstrates a concern of Brazilian nurses in following the trends of international nursing for greater communication effectiveness, and consolidation of a reference language to the profession. Therefore, this type of production should take an upward curve nationally and internationally, because the number of researchers with an interest in the subject is increasing.

The prevalence of studies produced in the Northeast region of the country may be related to the fact that in this region is located an ICNP® Centre linked to the Post-Graduate Program in Nursing of the Federal University of Paraíba (PPGENF-UFPB). The Centre for Research and Development of ICNP® PPGENF-UFPB was approved by the ICN in 2007. Its activities are in line with the three components of the life cycle of the ICNP® terminology, especially the production of terminology subsets, contributing to its use and continued development in clinical practice, and consolidation as a reference terminology. It also establishes partnerships with other educational institutions in several Brazilian states, contributing to the scientific production on the subject(⁵,⁸).

Regarding the methodological approach presented in the studies, the variety of clienteles and the health priorities selected for the development of the subsets include priority areas for health actions defined at national and international level, with specific public policies(¹⁹-²⁰). The construction of ICNP® subsets for these priority areas serves the purpose of producing nursing knowledge, which is to understand people’s needs and incorporate new technologies in health care, contributing to the improvement of clinical practice and to consolidate the Unified Health System (SUS – Sistema Único de Saúde).

The use of different research techniques to collect terms and concepts relevant for the clientele and the health priority, in addition to those recommended in the literature, shows versatility and creativity of the authors in developing strategies for the refinement or construction of new methodological possibilities for the development of these subsets, as recommended by the ICN(⁸,²¹).

The modeling stage of new concepts is crucial for the ICNP® evolutionary process, and also requires that authors use the creative process. It consists of adding new concepts or remodeling the existing concepts for better understanding its meaning and adjustment to the subset(⁵,²²). The fact that it was not mentioned in the dissertations analyzed denotes a weakness of these studies, because adding/editing terms and concepts allows the constant updating and development of this Classification, focused on its suitability to the language used in professional practice.

Another weakness found in the dissertations analyzed refers to the lack of standardization in the stage of content validation of the identified terms/concepts and of the statements of diagnoses, outcomes and nursing interventions developed from the same. It was found that there was no consensus on the criteria established for selecting the group of experts responsible for this process and they were not clearly described in the studies.

The ICN does not refer its own standardization criteria for selecting the committee of judges that should participate in the content validation process, hence the authors should establish the participation criteria. The literature is scarse and does not provide extensive comments on the subject, which can make the selection of experts a tough step to be fulfilled, because there are also obstacles related to the training and professional development of nurses, still deficient in many states of the country, particularly regarding the use of ICNP® in clinical practice(²³).

The improper choice of professionals involved in the content validation process can influence the reliability of the results, negatively affecting the structuring of the terminological subset. Therefore, it is recommended that the formation of the experts committee to validate the terms/concepts and statements of diagnoses, outcomes and nursing intervention should follow well-defined selection criteria, taking into consideration their qualifications by investigating the experience, knowledge, skills and practice of each professional involved in relation to what shall be validated(²³).

It is noteworthy that the process of clinical validation is also crucial for the completion of the subset, by which the statements constructed should be tested by carrying out clinical case studies with representative groups of the population regarding the chosen clientele, in order to check its applicability to nursing clinical practice and the use of a unified language for documenting the professional practice(²⁴). Thus, it is necessary that these subsets are clinically validated to ensure greater reliability of the results found.

The lack of detailing in the description of the significance for nursing and the theoretical framework observed in two studies meets the ICN recommendations for the presentation of the final work. This should be corrected in order to facilitate the understanding and relevance of the subset for clinical practice.

The theoretical framework most widely used in the analyzed studies was the Basic Human Needs by Wanda de Aguiar Horta. This may be related to the fact that this author was responsible for introducing the nursing process in Brazil, providing relevant contribution in the construction and dissemination of a new knowledge in nursing, and having, to this day, a strong influence on professional teaching and practice in the country(²⁵).

The publication of the subgroups analyzed in the form of scientific articles in journals and/or as papers presented at scientific events, both nationally and internationally, following the ICN recommendations, will allow the adoption of a standardized and specific language to diagnose, intervene and assess the outcome of care provided to individuals, families and communities in different areas of the nursing clinical practice worldwide. Its continued use will bring the following major benefits: 1) the improvement of its performance through more reflective, effective and efficient actions; 2) improvement of the communicative and relational process between nurses and other members of the multidisciplinary health care team; and 3) greater recognition and visibility to the profession in the different contexts and scenarios of clinical practice.

However, it is worth noting that these subsets do not replace the clinical judgment nor the decision-making process of nurses, which will always be essential to provide individualized care to clients and their families, as an accessible reference for these professionals. Its applicability, as well as its structuring based on the systematization of care, depends on the professional involvement in Nursing practice, supporting the solution of problems of people and/or the community(¹⁸).

Conclusion

The present study illustrates an overview of the scientific production of stricto sensu post-graduate studies in nursing in Brazil, in extracts of methodological research on ICNP®, focusing on the steps taken in the development of terminology subsets, enabling a greater visibility to the discussed issue.

The results showed consistency in the production of studies on the development of ICNP® terminology subsets by Brazilian nurses, demonstrating a concern for a unified language for the profession. The initiatives of some authors to systematize alternative methods for creating these subsets also stood out.

The main limitation of this study was related to the lack of detailing in the descriptions of some stages of the methodological approach adopted by the authors, making it difficult to assess the methodological rigor in the conduct of their work. The standardization of the steps followed for the development of ICNP® terminology subsets is crucial for their safe and effective application in nursing practice, translating into improvements in the various contexts of professional practice. Thus, the lack of uniformity regarding the conduct of studies, especially in relation to the content validation of the terms and concepts identified, should be corrected in future studies in order to ensure the reliability of the final product of such studies.

Finally, the study draws attention to the importance of investigations on the actions of nurses guided by scientific methods and with consistent theoretical basis. Therefore, it is suggested that new terminology subsets are developed using a well-defined methodological process, with their application and validation on the selected clientele in order to ensure greater reliability and consolidate a reference terminology to be used worldwide in the professional nursing practice.

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Publication Dates

• Publication in this collection
  Dec 2014

History

• Received
  12 Dec 2013
• Accepted
  19 Oct 2014