Validation of an evaluation matrix for the nursing process in the hospital context

Validación de una matriz de evaluación del proceso de enfermería en el contexto hospitalario

ABSTRACT

Objective:

To validate the content of an evaluation matrix for the nursing process in the hospital context.

Method:

A methodological study conducted in four stages, carried out from March to December 2022. Including: bibliographic research and selection of structuring foundations; construction of the logical model and analysis and judgment matrix; content validation by a committee of judges (n=11) using the Delphi technique; analysis of content validation data by calculating the Concordance Rate and Content Validity Index.

Results:

At the end of the two rounds, the matrix had a concordance rate of 90% regarding format and 100% regarding other structural aspects. It also had a 100% concordance rate regarding the scope and representativeness of the matrix domains. Regarding the average Content Validity Index, the values were 0.97 and 0.98, for clarity and representativeness, respectively.

Conclusion:

The evaluation matrix - consisting of four dimensions and fourteen evaluation items referring to the necessary stages for the implementation and operationalization of the nursing process - demonstrated excellent content validity, which can contribute to supporting institutional initiatives for its consolidation in hospital nursing services.

Descriptors:
Nursing process; Validation study; Hospitals; Nursing assessment; Nursing

RESUMEN

Objetivo:

Validar el contenido de una matriz de evaluación del proceso de enfermería en el contexto hospitalario.

Método:

Se realizó un estudio metodológico, realizado en cuatro etapas, realizadas de marzo a diciembre de 2022. Son: levantamiento bibliográfico y selección de fundamentos estructurantes; construcción del modelo lógico y matriz de análisis y juicio; validación de contenido por un comité de jueces (n=11) mediante la técnica Delphi; análisis de datos de validación de contenido mediante el cálculo de la Tasa de Acuerdo y el Índice de Validez de Contenido.

Resultados:

Al final de las dos rondas realizadas, la matriz tuvo un índice de acuerdo del 90% en cuanto al formato y del 100% en otros aspectos estructurales. También tuvo un índice de acuerdo del 100% respecto del alcance y representatividad de los dominios de la matriz. En cuanto al Índice de Validez de Contenido promedio, los valores fueron 0,97 y 0,98, en términos de claridad y representatividad, respectivamente.

Conclusión:

La matriz de evaluación - compuesta por cuatro dimensiones y catorce ítems de evaluación referentes a los pasos necesarios para la implementación y operacionalización del proceso de enfermería - demostró excelente validez de contenido, que puede contribuir a apoyar iniciativas institucionales para su consolidación en los hospitales con servicios de enfermería.

Descriptores:
Proceso de enfermería; Estudio de validación; Hospitales; Evaluación en enfermería; Enfermería

RESUMO

Objetivo:

Validar o conteúdo de uma matriz avaliativa do processo de enfermagem no contexto hospitalar.

Método:

Foi realizado um estudo metodológico, conduzido em quatro etapas, realizadas de março a dezembro de 2022. São elas: levantamento bibliográfico e seleção dos fundamentos estruturantes; construção do modelo lógico e da matriz de análise e julgamento; validação de conteúdo por um comitê de juízes (n=11) por meio da técnica Delphi; análise dos dados de validação do conteúdo por meio do cálculo da Taxa de Concordância e Índice de Validade de Conteúdo.

Resultados:

Ao final das duas rodadas realizadas, a matriz teve uma taxa de concordância de 90% quanto ao formato e 100% quanto os demais aspectos estruturais. Também teve uma taxa de concordância de 100% quanto à abrangência e representatividade dos domínios da matriz. Quanto ao Índice de Validade de Conteúdo médio os valores foram de 0,97 e 0,98, na clareza e representatividade, respectivamente.

Conclusão:

A matriz avaliativa - constituída por quatro dimensões e quatorze itens avaliativos referentes às etapas necessárias para implantação e operacionalização do processo de enfermagem - demonstrou ter uma excelente validade de conteúdo, o que pode contribuir para subsidiar iniciativas institucionais de sua consolidação nos serviços de enfermagem hospitalares.

Descritores:
Processo de enfermagem; Estudo de validação; Hospitais; Avaliação em enfermagem; Enfermagem

INTRODUCTION

Nursing has been sustained, as a profession and social practice, by several theoretical and methodological frameworks that allow the organization and systematization of care in different areas of health care1. When discussing these frameworks, the Nursing Process (NP) emerges as an important method for organizing care, through the documentation of professional practice and clinical reasoning supported by the ethical and legal aspects of nursing2^,3.

In 2024, the Federal Nursing Council (Conselho Federal de Enfermagem - COFEN) published a new resolution with updates for the proper implementation of the NP4, highlighting the importance of strengthening research focused on nursing care in various socio-environmental contexts.

Despite the recognized benefits of implementing NP in health services, such as greater qualification of competent, safe care capable of encompassing elements necessary for assertive decision-making and appropriate to society’s demands, it is known that this is still not a consistent reality in all health care settings5^,6.There are scenarios in which the implementation still faces institutional and operational limitations, such as problems with staffing and work overload, lack of team knowledge and weaknesses in the strategies for including professionals in the planning, decision-making and permanent education processes6^,7. This can result in a fragmented NP, disconnected from local realities, and consequently restrict its social recognition and appreciation by management8^,9.

In some local scenarios experienced by the authors, it is evident that the implementation of the NP still occurs without adequate adaptation to the reality of the service. This can result, among other factors, in the accumulation of forms, paperwork, questionnaires and requests that are “implemented” in services without proper adaptation of the proposal to the service’s specificities, without the inclusion of the nursing team in planning or without adoption of validated instruments.

At the same time, through a literature search conducted in 2022, through the Virtual Health Library (VHL) and PubMed, using the descriptors and their corresponding ones: “nursing process”; “validation studies”, “nursing assessment” and “hospitals”, it was identified that validation studies on NP in the hospital context focus on specific stages, such as, clinical validation of diagnoses, preparation of histories and validation of nursing plans and interventions for specific scenarios in the hospital context10^-14. Therefore, no validated instruments were found with an emphasis on evaluating the NP implementation and execution, which could bring an innovative aspect to this research.

Given this discussion, after several legal and training advances for the implementation of NP in care production settings, concerns arise that solidify a guiding question that has not yet been completely answered by research in the nursing field: is it possible to validate the content of an evaluation matrix of the nursing process in the hospital context?

Thus, the justification for conducting this study is based on the need for the nursing team to assume their primary functions in caring for the individual, in a systematic and evidence-based manner. There may still be a demand for scientific instruments that can guide nursing services in structuring the NP. Moreover, this research proposal presents an innovative character, as it considers the situational context of health services during the NP implementation process.

A properly scientifically validated instrument could assist in the proper operationalization of the NP, so that managers and coordinators of hospital services can verify and follow all the necessary steps/phases to adapt the NP to the reality of the services and thus achieve more effective and impactful results in the quality of professional care2^,14^,15. Therefore, this study aimed to validate the content of an evaluation matrix for the nursing process in the hospital context.

METHOD

This is a methodological study involving the construction and validation of an evaluation matrix for the nursing process in the hospital context. The proposed instrument was subjected to a validation process, using the Content Validity (CV) technique, which assesses the representativeness of the proposed content in each of the items of a constructed instrument16^,17. Therefore, the following methodological stages were adopted successively from March to December 2022:

First stage: bibliographic research and selection of structuring foundations

The first stage was conducted from March to May 2022. It consisted of searching for national and international references that could assist in the selection of structuring foundations. Extensive research was conducted on the official website of the Federal Nursing Council (COFEN), as well as in Health Sciences databases, such as the Virtual Health Library - Nursing (BDENF) and PubMed. This search supported the elaboration of the conceptual framework, that is, on the nursing process in the hospital context in the light of nursing theories and legal norms and publications of COFEN.

After selection and synthesis of the bibliographic research, the basis references were defined regarding the technical2^,4^,18^-20⁾ and theoretical21⁾ foundations that supported the essential concepts relevant to the theme to address the proposed objective, which allowed the structuring of the logical model and development of domains and structuring items of the evaluation matrix for the nursing process in the hospital context.

Second stage: construction of the logical model and the analysis and judgment matrix (AJM)

The second stage was conducted in June and July 2022. Based on the bibliographic research, conceptual properties were established, as well as the structuring of the logical model and the dimensions and items of the evaluation matrix for the nursing process in the hospital context. Here, logical model is defined as a methodological approach that integrates the description of ideas, hypotheses and expectations forming the structure of a given project. From this structural design, the evaluation indicators (evaluation matrix) with their respective domains and items are drawn up, therefore, the logical model works as the first structural design that will originate the evaluation matrix22^,23.

This structuring was carried out based on the moments of Situational Strategic Planning (SSP): explanatory, normative, strategic, and tactical-operational moment. The SSP, founded by Carlos Matus, was chosen as the theoretical framework for the structural basis of the matrix because it allows an effective articulation between the planning, execution, and evaluation of nursing professional practice, based on its structural moments. Therefore, it is in line with the purposes of the nursing process18^,21.

From the SSP structure, the logical model and conceptual dimensions of the Analysis and Judgment Matrix (AJM) were consolidated. Subsequently, the representative aspects of the theoretical-legal basis of the NP were developed, which were consolidated into matrix elements such as: indicators, evaluative questions, parameters/standards, response scale and verification sources.

The construction of the items and response scale was carried out based on the most used validation study criteria: objectivity, simplicity, clarity, precision, relevance, and interpretability. The objective of adopting these criteria was to eliminate aspects that could be ambiguous, incomprehensible, as well as vague terms, double questions, jargon or any other statements that refer to value judgments17.

Furthermore, a validation questionnaire for the judges was created, so that the expert committee could validate the content of the logical model and the evaluation matrix. This questionnaire has an objective structure and sequence, with the purpose of reducing the physical and/or mental effort of the judges and ensuring the evaluator’s interest until the end of the instrument. It was divided into three parts: 1 - Instructions to judges regarding its completion and the objectives of the study; 2 - Characterization of the judges; 3 - Content validation questionnaire for the logical model and evaluation matrix, subdivided into two stages.

The first stage consisted of the global evaluation of the instrument and its dimensions. At this point, two criteria were considered: the scope of the domains, whether each domain was adequately represented by the set of items, and whether the content expressed in each domain was representative. Also in this global evaluation, the general aspects of the logical model and the evaluation matrix were also subjected to evaluation, such as title and format (layout). At this stage, the judges’ responses were based on “Agree” and “Disagree”. Furthermore, suggestions for textual adjustments could be made16^,17.

The second stage consisted of the evaluation of each item in the evaluation matrix. For this evaluation, two criteria were adopted: clarity and relevance/representativeness. Regarding clarity, it was expected that the items were written in a way that the concept was clear, understandable, and able to adequately express what was being measured. Meanwhile, the relevance or representativeness of the items was evaluated through relevance and suitability for the proposed objectives16^,17.

A four-point Likert scale was used for the evaluation of the two criteria. When evaluating the clarity criterion, the following were considered: 1 = not clear, 2 = unclear, 3 = quite clear and 4 = very clear. In the “relevance/representativeness” criterion, the following were considered: 1 = not relevant or not representative, 2 = item needs major revision to be representative, 3 = item needs minor revision to be representative and 4 = relevant or representative item. Furthermore, in items with low score, there was room for descriptive suggestions by the evaluators.

Third stage: content validation by the committee of judges

The third stage took place between August and December 2022, considering the two rounds conducted. For this validation stage, the modified Delphi Technique was used, which consists of a systematized process of evaluating and judging instruments through consensus among experts in a particular field. This technique can commonly be performed in several rounds17^,22. In this study, two rounds were necessary.

The inclusion criteria for the judges were: postgraduate nurses (master’s or doctoral degree), with research experience and publication on the nursing process and/or researchers who are experts in methodological knowledge, with experience in instrument construction and validation. At the same time, the following were included in the committee of judges: clinical nurses and nursing coordinators from hospital services. The inclusion of these professionals is because they are part of the instrument’s target audience (nursing professionals in the hospital context). This inclusion aimed to ensure the correction of unclear phrases and terms, for greater comprehensibility of the instrument17.

For the selection of judges, a search was conducted through curriculum analysis in the Lattes platform database. The search terms in the SUBJECT tab were: “validation study” and “nursing process”. Initially, 1426 profiles were filtered. After a preliminary analysis of the curriculum presentation text, 145 were selected. The curriculum was then read, which resulted in the selection of 41 invitations to judges with the aforementioned criteria. Additionally, four nurses working in the hospital service were selected. They were selected through the official websites of public hospital institutions in the state of Bahia. This selection took place in just one federative unit for logistical reasons to operationalize the search.

After selection, an invitation letter was sent via email to the experts. It explained the criteria for choosing judges, the objectives, and concepts necessary to understand the study proposal. Additionally, the Informed Consent Form (ICF) was sent for participation in the research and requested to be returned within a period of up to ten days.

Thus, for this validation, initially, 45 judges were invited, with an adherence of 24.44%, that is, 11 participants (09 judges with Masters/Doctoral and 02 professionals from the hospital service) until the end of the two rounds necessary for the search. After the judges’ consent, the first round of validation began by sending two documents to be completed, also electronically: the first constructed version of the logical model and the evaluation matrix and the validation questionnaire for the judges with instructions on how to proceed with the evaluation and how to complete it. A period of up to fifteen days was requested for completion and return by the study participants for each round.

At the end of the first round, with the instruments evaluated by the researchers returned, agreement calculations were performed, and changes considered relevant to the instrument were made, based on the references, to ensure adequate content validation. It is important to highlight that in addition to the quantitative data, the judges’ notes were carefully considered and compared to the structuring literature17.

Thus, the adjustments requested in the instrument were assessed and implemented. After this, the instrument was sent back to the judges for the second round of evaluation, with the aim of providing a new assessment, given the changes made and, consequently, increasing the level of agreement among the experts. Participants were able to maintain or not the suggestions from the first round, as well as make changes to the agreement scale for each item of the matrix in question.

Fourth stage: analysis of content validation data

The fourth stage occurred parallel to the third stage, that is, from August to December 2022. After each round, with the instruments returned to the researchers, statistical tests were conducted to verify agreement among the judges. Data from the first stage evaluation were submitted to the calculation of the Concordance Rate (CR), which has an overall range in terms of agreement between the evaluators. The CR represents the calculation of the percentage of agreement in each domain or aspect evaluated and for this adequacy a concordance rate equal to or greater than 90% was adopted17^,24.

Meanwhile, the data obtained in the second stage were subjected to calculation of the Content Validity Index (CVI), which measures the percentage of judges who agree on the individual aspects of the instrument’s items. Unlike the CR, the CVI individually evaluates each item of the instrument and is calculated considering the number of responses with the highest agreement (in this case, Likert 3 and 4) divided by the total number of responses17.

Based on this calculation, items that received scores of “1” or “2” were reviewed or eliminated. In addition to calculating the items, the average evaluation of the instrument items was also performed. To be considered valid, a minimum agreement of 0.80 was expected and preferably greater than 0.90 given that it was the content validation of a new instrument in the study scenario17^,24.

The research was conducted in compliance with the ethical and scientific requirements contained in the resolutions of the National Health Council (Conselho Nacional de Saúde - CNS). The research project was submitted and approved by the Research Ethics Committee (REC) of the Universidade Estadual de Feira de Santana, under opinion 5,469,335/2022.

RESULTS

The majority of judges were doctors (63.63%) and worked in the state of Bahia (63.63%) (Table 1). The number of judges was the same in both rounds conducted.

Table 1 -
Characterization of judges regarding education level and federative unit of professional activity. Feira de Santana, Bahia, Brazil, 2022

Variables	n (%)
Education Level
Doctorate degree	7 (63.64)
Master’s degree	2 (18.18)
Specialization*	2 (18.18)
Federal Unit of Activity
Bahia	7 (63.64)
São Paulo	1 (9.09)
Goiás	1 (9.09)
Santa Catarina	1 (9.09)
Minas Gerais	1 (9.09)

• Source: Research data, 2022.
• Notes: *Judges with a specialization degree were professionals working in hospital services, who did not require a minimum Master’s degree to participate in the research.

The validation rounds consisted of two stages. The first referred to the overall evaluation of the instrument and its dimensions. Thus, the judges evaluated the general aspects of the logical model and the evaluation matrix. In this process, the judges pointed out the need for adjustments to the title. From EVALUATION MATRIX OF IMPLEMENTATION AND EXECUTION OF THE NURSING PROCESS IN THE HOSPITAL CONTEXT it was changed to EVALUATION MATRIX OF THE NURSING PROCESS IN THE HOSPITAL CONTEXT.

Regarding the format of the Matrix, adjustments were proposed in the column titles and in the RESPONSE SCALE. The responses were synthesized from four to three levels, as there was no clear delimitation between them. Additionally, these levels received definitions at the footer of the Matrix, as well as quantifiable values to reduce subjectivity in the evaluation process, based on the parameters defined for the matrix.

The existing Dimensions in the Matrix - constructed from the SSP moments - were evaluated as adequate by the judges, both in terms of “scope” and “representativeness of the content”. Therefore, no adjustments were necessary. Thus, at the end of the rounds, the concordance rate regarding the overall evaluation was considered satisfactory (Table 2).

Table 2 -
Concordance Rates (CR) in the first stage of Instrument Evaluation (Overall Evaluation) in the first and second validation rounds. Feira de Santana, Bahia, Brazil, 2022

Variables	CR (1st round)	CR (2nd round)
Logic model	100 %	100 %
Matrix Title	63.63%	100 %
Matrix Format	63.63%	90 %
Scope of Dimensions
A. Explanatory	100 %	100 %
B. Normative	100 %	100 %
C. Strategic	100 %	100 %
D. Tactical-Operational	100 %	100 %
Representativeness of Dimension Content
A. Explanatory	100 %	100 %
B. Normative	100 %	100 %
C. Strategic	100 %	100 %
D. Tactical-Operational	100 %	100 %

• Source: Research data, 2022.

At the end of the first round, the CVI for clarity ranged between 0.80 and 1.0, with an average CVI of 0.90± 0.06. The CVI for representativeness also ranged between 0.80 and 1.0, with an average CVI of 0.93± 0.04. At the same time, the judges made suggestions for improvement that were appreciated by the researchers. In addition to word adjustments in all indicators, some specific adjustments were made to the Matrix. They are: A1: addition of participatory methodologies; B1: addition of words in the situation-objective conceptualization; B3: addition of words in the description of supporting operational systems; C1: detailing the concepts of strengths, weaknesses, threats and opportunities; C2: detailing the concepts of viability; C3: specification of Permanent Education (PE) actions for the PE; D1 and D2: language adjustment in line with COFEN resolution nº358/2009 and spelling correction; D3 and D4: addition of information about nursing prescription and adequate and safe checking; D6: inclusion of complementary words; D7: grouping of monitoring and evaluation of the PE in the same item. D8: exclusion of the item to avoid information redundancy.

Thus, at the end of the second round, after making the adjustments pointed out by the judges, the CVI for clarity ranged between 0.90 and 1.0 and the average CVI was 0.97± 0.06. In terms representativeness, the CVI also ranged between 0.90 and 1.0, but with an average CVI of 0.98± 0.04 (Table 3).

Table 3 -
Content Validity Items (CVI) in the second stage of Instrument evaluation the during the first and second round of validation. Feira de Santana, Bahia, Brazil, 2022

Items	CVI - Clarity (1st round)	CVI - Clarity (2nd round)	CVI - Representativeness (1st round)	CVI - Representativeness (2nd round)
A1-Problem tree constructed in the organizational context (actors, techniques, and instruments).	0.90	1	0.90	1
B1- Objective situation of the NP constructed from the mission, vision and values of the institution and the nursing service, as well as the actors, techniques and instruments involved.	0.90	0.90	1	1
B2- Existence of at least one adopted nursing theory.	1	1	1	1
B3-Existence of supporting operational systems for the implementation and operationalization of the NP.	0.90	1	0.90	0.90
C1-Conducting a strategic assessment with the analysis of limiting and facilitating factors for the implementation and execution of the NP.	0.80	0.90	0.90	0.90
C2-Carrying out feasibility analysis (political, economic, and institutional-organizational).	0.80	0.90	0.90	1
C3-Existence of team Permanent Education strategy.	0.90	1	1	1
D1-Carrying out data collection with the user to collect information through history and physical examination.	0.90	1	0.90	1
D2-Carrying out nursing diagnoses construction practice.	0.90	1	1	1
D3-Carrying out nursing planning practice.	0.90	1	1	1
D4-Carrying out nursing actions and interventions implementation practice.	0.90	1	0.90	1
D5-Carrying out nursing evaluation practice.	1	1	1	1
D6-Carrying out nursing records practice.	1	1	0.90	1
D7-Existence of NP monitoring and evaluation.	0.90	0.90	0.90	0.90
D8 -Existence of NP evaluation.	0.80	*	0.80	*
	Mean CVI: 0.90	Mean CVI: 0.97	Mean CVI: 0.93	Mean CVI: 0.98

• Source: Research data, 2022.
• Notes: * Item excluded in the second round as suggested by judges.

Furthermore, with the publication of the new COFEN resolution on the NP in January 20244, the authors updated Dimension D of the logical model and the evaluation matrix, as it relates directly to the stages described in the new normative. It was not necessary to resubmit the instruments to a new validation process, as the adjustments made are restricted only to the notes of this new legal framework, which is relevant and representative to the class council, professionals and society. Additionally, the other dimensions involve operational aspects prior to the execution of the NP stages.

Thus, the updates made were: Indicator D1 (updating the title of this stage to Nursing Assessment and textual adjustment to its respective evaluation parameter); adjustment in the descriptive text of the parameters of indicators D2, D3 and D4 in line with the new concepts brought by the resolution, such as prioritization of diagnoses, therapeutic decision-making and standards of care; and Indicator D5 (updating the title of this stage to Nursing Evolution and textual adjustment to its respective evaluation parameter).

For its applicability, it is observed that each dimension is composed of a group of items and, therefore, each item is made up of evaluative questions associated with its respective purpose/parameter. When applying it, the evaluator marks the corresponding response scale to the evaluative item, which consists of three values: (3) fully performed; (2) partially performed; (1) not performed in the service. To do this, the instrument provides a detailed description of each of these values on the response scale. Finally, the sum of points on the response scale varies between 15 (lowest value) and 45 (highest value). The higher the value, the better the sector/service is evaluated regarding the implementation and execution of the NP. Thus, we have the final version of the logical model (Figure 1) and the evaluation matrix (Chart 1) - with their respective dimensions and items - after two rounds of validation by the committee of experts and the updating process according to the current COFEN guidelines.

Figure 1 -
Final version of the Logical Model for Evaluation of the Nursing Process in the hospital context. Feira de Santana, Bahia, Brazil, 2022

Chart 1 -
Final version of the Evaluation Matrix of the Nursing Process in the hospital context. Feira de Santana, Bahia, Brasil, 2022

DIMENSION	INDICATOR	EVALUATIVE QUESTION	PURPOSE (PARAMETER)	RESPONSE SCALE*	SOURCES
A -EXPLANATORY Analysis of the organizational context to identify the central problem related to the implementation of the NP, as well as the selection and prioritization of problems associated with the hospital context.	A1- Problem tree constructed in the organizational context (actors, techniques, and instruments).	Was the need for implementing the NP discussed as the central problem identified in the organizational context? Who formulated it, and which actors were involved? What methodologies and instruments were used in this formulation?	It is important to identify the central problem from the perspective of the multiple actors existing in the situational scenario (managers, nurses, technicians and nursing assistants, among others). Furthermore, it is relevant to adopt participatory methodologies (workshops, guided debates, conversation circles, among others) and instruments (flowcharts, situational maps, legislation, among others).	(3) Fully performed (2) Partially performed (1) Not performed in the service	Interview Institutional Documents (meeting records, communications, notices, reports, protocols, among others).
		Was a problem tree constructed regarding the current situation with its causes, consequences and priority problems associated with the implementation of the NP in the unit? Which actors, methodologies and instruments were involved in this construction?	The problem tree should be constructed based on the central problem with details of its causes/critical nodes and consequences. It should involve the study of the current situation through the identification, survey and analysis of priority problems related to the implementation of the NP. It is also necessary to identify the involvement of actors in the thematic scope, as well as the adoption of participatory methodologies (workshops, guided debates, conversation circles, among others) and instruments (flowcharts, situational maps, legislation, among others)	(3) Fully performed (2) Partially performed (1) Not performed in the service
B-NORMATIVE Construction of the situation-objective for implementing the NP, as well as the actions necessary for its implementation.	B1-Situation-objective of the NP constructed from the mission, vision and values of the institution and the nursing service, as well as the actors, techniques and instruments involved.	How was the situation-objective of the NP constructed in the unit? Did this construction consider the mission, vision and values of the institution and the Nursing service? Which actors, methodologies and instruments were used?	The situation-objective consists of structuring the new situation to be achieved through an intervention plan on the problems described, based on the local reality. The implementation of the NP must consider the mission, vision and values of the institution and the nursing service, in line with the recommendations of the Nursing Councils. It is necessary to involve all nursing professionals in this construction through participatory methodologies (workshops, guided debates, conversation circles, among others) and instruments (flowcharts, situational maps, legislation, among others).	(3) Fully performed (2) Partially performed (1) Not performed in the service	Interview Institutional documents (medical records, systems, meeting records, reports, routines, protocols, regulations, among others).
	B2 - Existence of at least one adopted nursing theory.	Was it discussed and defined which nursing theory to adopt as theoretical support for the stages of the NP? Who discussed it and what elements were considered for the definition of the theory?	The NP must be based on theoretical support that guides it at all stages. Furthermore, the definition of the theory to be adopted must consider the participation of existing actors in the organizational context, as well as the care purposes and the specificities of the service.	(3) Fully performed (2) Partially performed (1) Not performed in the service
	B3 - Existence of operational support systems for the implementation and operationalization of the NP.	Are there operational support systems for the implementation and operationalization of the NP?	Accessible and easy-to-use operational support systems must be adopted for the implementation and operationalization of the NP (software, instruments, forms, among others) that address the stages of the NP, in a clear, objective manner, compatible with the organizational context and that encourage the critical-reflective thinking.	(3) Fully performed (2) Partially performed (1) Not performed in the service
C-STRATEGIC Analysis of limiting and facilitating factors for implementation and execution of the NP, as well as verification of feasibility.	C1-Carrying out a strategic assessment with the analysis of limiting and facilitating factors for the implementation and execution of the NP.	Have the strengths, weaknesses, opportunities and threats that facilitate or limit the implementation and execution of the NP in the unit been identified?	It is important to identify the strengths and weaknesses (advantages and disadvantages of the internal context of the analyzed services, respectively) and opportunities and threats (favorable and unfavorable aspects of the external context in which the analyzed unit is inserted, respectively) regarding the implementation of the NP, based on the specificities of the existing sectors in the hospital service (wards, intensive care services, surgical center, among others). From this, if necessary, a sector of the unit can be chosen for a pilot project to implement the NP.	(3) Fully performed (2) Partially performed (1) Not performed in the service	Interview Institutional documents (meeting records, reports, communications, routines, protocols, regulations, among others).
	C2-Carrying out feasibility analysis (political, economic and institutional-organizational).	Were the political, economic and institutional-organizational feasibility for implementing the NP analyzed?	Feasibility analysis can be performed at three levels: political feasibility (institutional negotiations to agree on common paths of action); economic feasibility (which must respond to what is economically viable, such as acquisition of systems, implementation of programs, among others); and institutional-organizational feasibility (institutional and logistical support for the implementation and execution of the NP).	(3) Fully performed (2) Partially performed (1) Not performed in the service
	C3- Existence of a Permanent Education strategy for the team.	Is there a permanent education strategy about the NP? If yes, who is it directed to?	Permanent education is a necessary strategy for the effective implementation of NP and must involve practical training with all members of the nursing team. It should focus on problematizing everyday processes present in the work context, such as specific stages of the NP that present more obstacles to execution.	(3) Fully performed (2) Partially performed (1) Not performed in the service
D-TACTICAL-OPERATIONAL Concrete action to implement the NP stages in the hospital context, as well as monitoring and evaluating the execution.	D1 - Carrying out the nursing assessment.	Is there data collection to obtain information about nursing care needs? Who carries it out, how and what tools are used?	Initial and continuous subjective (interview) and objective (physical examination) data collection must be performed, using techniques (laboratory and imaging, clinical tests, validated assessment scales, institutional protocols and others) to obtain information about the nursing and health care needs relevant to practice;	(3) Fully performed (2) Partially performed (1) Not performed in the service	Interview Institutional documents (medical records, meeting records, reports, routines, protocols, among others). Direct observation
	D2 - Carrying out Nursing Diagnosis Construction Practice.	Is there practice in constructing nursing diagnoses? Who performs it, how and what tools are used?	Nursing diagnoses must be constructed based on existing problems, conditions of vulnerability or dispositions to improve health behaviors. They must be grounded on nursing theories and compatible with the information collected by the nursing assessment. This should be an activity exclusive to nurses.	(3) Fully performed (2) Partially performed (1) Not performed in the service
	D3 - Carrying out nursing planning practice	Is the nursing planning carried out? Who performs it, how and what tools are used?	Planning must be carried out through a targeted care plan shared with the subjects of care and the Nursing and healthcare team. It must involve: Prioritization of Nursing Diagnoses; Determination of expected and achievable nursing and health results (quantitative and/or qualitative); Therapeutic decision-making, declared by the nursing prescription of interventions, actions/activities and care protocols. Prescribing nursing actions and interventions is a nurse's exclusive activity. It must contain the complete identification of the user and be in line with the materials and technological resources available in the unit, have clear and objective language, as well as adequate scheduling and checking in a safe and consistent way with the actions performed, in addition to spaces for individualized detailing of actions and materials to be used, if necessary.	(3) Fully performed (2) Partially performed (1) Not performed in the service
	D4-Carrying out nursing actions and interventions implementation practice.	Is there practice of implementing nursing actions and interventions through nursing prescriptions? Who performs it, how and what tools are used?	The planned interventions, actions and activities must be carried out by the nursing team, based on the planning, based on nursing prescriptions updated daily and whenever necessary, in an individualized manner and with an appropriate checking system, respecting the appropriate technical skills. Implementation must be supported by Nursing, Interprofessional or Health Program standards of care.	(3) Fully performed (2) Partially performed (1) Not performed in the service
	D5 - Carrying out Nursing evolution.	Is there a nursing evolution practice? Who performs it, how and what tools are used?	The evaluation must be carried out by the nursing team, daily and whenever necessary, based on the results achieved, according to recommended nursing theory, compatible with the other stages of the Nursing Process. The evaluation must also include analysis and review of the entire Nursing Process.	(3) Fully performed (2) Partially performed (1) Not performed in the service
	D6 - Carrying out nursing records practice.	Is there a practice of nursing records? Who performs it, how and what tools are used?	Records must be made by the nursing team daily and whenever necessary, in a specific operational system, with relevant data from the NP stages, in a clear and objective manner, in compliance with current resolutions of the Nursing Councils. The nurse is responsible for recording all the steps.	(3) Fully performed (2) Partially performed (1) Not performed in the service
	D7 - Existence of monitoring and evaluation of the NP.	Are there continuous monitoring and evaluation strategies for the execution of the NP in the unit? Who performs it, how and what tools are used?	It is necessary to adopt continuous monitoring and evaluation strategies for the execution of the NP, at all stages, along with members of the nursing team, based on the analysis of the implementation of actions and nursing records, verification of the degree of satisfaction of the team and users, analysis of the impact of the NP on institutional goals and updating of goals and deadlines compatible with local realities.	(3) Fully performed (2) Partially performed (1) Not performed in the service
DESCRIPTION OF THE RESPONSE SCALE*: (3) Fully performed: actions are carried out fully in accordance with the parameter indicated in the matrix.(2) Partially performed: actions are carried out partially in accordance with the parameter indicated in the matrix. (1) Not performed in the service: actions are not carried out in accordance with the parameter indicated in the matrix. The total points on the response scale range from 15 (lowest value) to 45 (highest value). The higher the value, the better the service was evaluated regarding the Nursing Process.

• Source: Research data, 2022.

DISCUSSION

An important aspect considered to ensure content validity was the quality of the expert panel. The greater participation of judges with doctoral degree is a positive aspect, given their experience in validation research and/or on the NP. Simultaneously, participants from different Brazilian states contributed to the evaluation of the instrument from multiple perspectives, considering the diverse regional experiences existing in a country of continental proportions. Finally, the participation of two judges who are active professionals in the hospital service represents the participation of the target audience in the instrument evaluation, especially to ensure greater comprehensibility of the proposed textual content. Moreover, the number of judges was 11, which is considered adequate for the content validity of instruments in the healthcare area17.

Given the structure of the instrument, validation in two rounds with a high rate of agreement and a mean CVI above 0.90, which is above the recommended minimum24, demonstrated that the matrix has excellent content validity and raised expectations of the instrument being applicable to hospital services, since a potential of the proposed instrument is its possibility of adaptation to different organizational contexts (such as hospital subsectors), as well as the valorization of existing actors, resources and operational systems, according to the prerogatives of the SSP itself18.

It is worth emphasizing that this is possible due to the structural similarity between the SSP and the NP, as both have dynamism between their moments, which deviate from a rigid and normative standard, as well as considering the existence of real problems, the establishment of desired results, the involvement of actors and concurrent execution of actions4^,21.

The contributions of the judges provided greater clarity to the sentences described in the instrument, especially through the detailing of some key concepts that were incorporated from the SSP. Language adjustments were necessary to make the instrument more understandable to the reader. The suppression of part of the title, especially the detail “(...) implementation and execution (...)” was done to provide greater objectivity to the text and avoid ambiguity with the stages of the NP itself.

Thus, adjustments were introduced to provide greater objectivity to the evaluative purpose of the instrument. Therefore, the validation stage by the expert committee was fundamental for the refinement commonly required in this type of study.

The aspects about the NP considered essential for the instrument were: adoption of nursing theories as theoretical support, use of operational and technological systems, nursing records, and execution of the stages of the NP: nursing assessment, nursing diagnoses, nursing planning, implementation and evolution of nursing. Then, in each essential aspect of the NP, operational details were introduced to make the instrument more applicable in healthcare services4^,25.

The emphasis on nursing theories was based on the need to highlight their capacity to reflect on nursing problems, thus enabling nurses to have greater autonomy in planning and executing the care provided. Undoubtedly, the adoption of nursing theories can promote improvements in the quality of care, as nurses move from being a simple executor of repeated tasks and becomes an active subject and protagonist of the healthcare process5^,26^,27.

Regarding nursing records, these were highlighted in the matrix due to their importance in enabling safe communication among nursing professionals and the healthcare team, as well as for purposes related to education, research, clarification of ethical and legal processes, and for evaluating the quality of nursing care provided4^,20.

The use of operational systems that contribute to the execution of the NP stages in the different contexts of care practice was one of the central axes of the content laid out in the matrix. Thus, the details of the execution of the NP phases were carried out based on the concepts and properties that underlie official publications on the NP today2. Evidence was also given to Permanent Education as an important resource for the implementation of the NP, based on the involvement of the different actors who participate in the practice scenario28. Associated with this, emphasis was placed on the need for continuous monitoring and evaluation of the implemented NP to foster improvement initiatives based on local realities21^,29^,30.

Therefore, the proposed instrument can foster discussions about the importance of bringing the theoretical content and the legal framework closer to the reality in which the subject is inserted. Consequently, from there, perspectives of real NP implementations in professional practice scenarios can be constructed, distinct from the rigid and utopian and nursing systems that are dissonant with local realities, still existing in some healthcare settings.

In view of this, this research presents innovative elements in the scenario of validation studies on NP: validation of an instrument that considers not only the execution of the stages themselves - assessment, diagnosis, planning, implementation, and evolution - but also the stages that precede the execution of the NP, based on the SSP. Thus, the instrument can dialogue with new studies and instruments produced in the area by bringing focus to the need for planning for the implementation of NP in the service, such as identifying existing problems, participation of professionals, definition of nursing theories, feasibility analysis, among others.

Finally, the expert committee considered that the instrument's indicators have the necessary clarity and relevance to be used in the evaluation of the NP and, consequently, encourage institutional initiatives for adaptations, adjustments, and reformulations of strategies for the NP consolidation in healthcare services. Which, therefore, contributes to strengthening the implementation and execution of the NP in hospital services.

Limiting factors of the study were identified, such as the response rate of experts, when compared to the number of invitations made for assessment, evaluation and return of the instrument in a timely manner, although the number of judges participating in the two rounds is within the recommended. Additionally, content validation is not the final phase at which evaluative instruments are commonly assessed. It is expected that this instrument undergoes pre-testing in the practice setting and more processes and agreement tests will be conducted to achieve other criteria and attributes, such as sensitivity, reliability and practicality in daily professional life. No information biases and/or confounding were identified.

CONCLUSION

The results of this study show that the proposed matrix shows a satisfactory concordance rate and CVI above the recommended average. The validated final version consisted of four dimensions (explanatory, normative, strategic, and tactical-operational) and fourteen evaluation items with their respective indicators, evaluation questions, purposes/parameters, response scales and search sources. These matrix elements allow the evaluation of the adequacy of the actions performed in the services for the effective implementation and operationalization of the NP.

The construction of this instrument had a well-defined theoretical basis, and the methodological steps were based on validation references. At the same time, the theoretical articulation of SSP with the NP, based on the structuring of the respective evaluation moments, configures an innovative approach in this field of knowledge. It is also noteworthy that the matrix is already aligned with the updates proposed by the new COFEN resolution on the NP.

Consequently, the research conducted has brought contributions to the advancement of the topic studied, especially for professionals working in healthcare services, expanding the possibilities for the implementation and operationalization of the NP, considering local realities and the consolidation of the NP as an important instrument for improving care provided to the human person and the community.

The presented instrument, therefore, provides subsidies for the improvement and development of professional nursing practice, considering that the NP needs to be seen, discussed and worked on not as a simple item of bureaucratic compliance to be executed by institutions in service routines, but as a tool for valuing the work process of the nursing team, under the leadership and planning of the nurse, providing opportunities for SSP in nursing care, the organization of nursing actions and the development of clinical-reflective reasoning, where the nursing team emerges as a protagonist in the practice setting, supported by institutional, legal, political and social support.

Acknowledgments:

This study was conducted with funding from the CAPES-COFEN Agreement (Notice No. 28/2019).

REFERENCES

• 1. Santos GLA, Sousa AR, Félix NDC, Cavalcante LB, Valadares GV. Implications of nursing care systematization in Brazilian professional practice. Rev Esc Enferm USP. 2021;55:e03766. doi: https://doi.org/10.1590/S1980-220X2020023003766
  » https://doi.org/10.1590/S1980-220X2020023003766
• 2. Conselho Regional de Enfermagem de São Paulo. Processo de enfermagem: guia para a prática. 2. ed. São Paulo: COREN-SP; 2021.
• 3. Junior WL, Braga CG, Freire BSM, Costa ACB, Andrade MBT, Chini LT, et al. (2023). Documentação do processo de enfermagem: desafios e potencialidades. CLCS. 2023;16(8):9416-41. doi: https://doi.org/10.55905/revconv.16n.8-075
  » https://doi.org/10.55905/revconv.16n.8-075
• 4. Conselho Federal de Enfermagem (BR). Resolução nº 736 de 17 de janeiro de 2024. Dispõe sobre a implementação do Processo de Enfermagem em todo contexto socioambiental onde ocorre o cuidado de enfermagem. Diário Oficial União. 2024 jan 23 [cited 2024 Feb 11];162(16 Seção 1):74. Available from: https://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?data=23/01/2024&jornal=515&pagina=74&totalArquivos=76
  » https://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?data=23/01/2024&jornal=515&pagina=74&totalArquivos=76
• 5. Almeida SLP, Primo CC, Almeida MVS, Freitas PSS, Lucena AF, Lima EFA, et al. Guide for systematization of care and nursing process: educational technology for professional practice. Rev Bras Enferm. 2023;76(Suppl 4):e20210975. doi: https://doi.org/10.1590/0034-7167-2021-0975
  » https://doi.org/10.1590/0034-7167-2021-0975
• 6. Sousa BVN, Lima CFM, Félix NDC, Souza FO. Benefícios e limitações da sistematização da assistência de enfermagem na gestão em saúde. J Nurs Health. 2020;10(2):e2010200. doi: https://doi.org/10.15210/jonah.v10i2.15083
  » https://doi.org/10.15210/jonah.v10i2.15083
• 7. Lourençone EMS, Medeiros JGT, Paz AA, Caregnato RCA. Sistematização da assistência de enfermagem: produção científica de uma década da Revista Enfermagem em Foco. Enferm Foco. 2022;13:e-202210. doi: https://doi.org/10.21675/2357-707X.2022.v13.e-202210
  » https://doi.org/10.21675/2357-707X.2022.v13.e-202210
• 8. Matzembacher EP, Meschial WC, Adamy EK, Arboit J, Argenta C, Bitencourt JVOV. Nurses’ perceptions about the operationalization of the nursing process in an emergency room. Rev Pesq Cuid Fundam. 2023;15:e-11933. doi: https://doi.org/10.9789/2175-5361.rpcfo.v15.11933
  » https://doi.org/10.9789/2175-5361.rpcfo.v15.11933
• 9. González-Alcantud B. Barriers to the application of the nursing methodology in the Intensive Care Unit. Enferm Intensiva. 2022;33(3):151-62. doi: https://doi.org/10.1016/j.enfie.2021.12.002
  » https://doi.org/10.1016/j.enfie.2021.12.002
• 10. Andrade LL, Costa MML, Fernandes MGM, Mangueira SO, Freire MEM. Validation of a nursing assessment for hospitalized individuals with infectious diseases. Rev Eletr Enferm. 2019;21:56571. doi: https://doi.org/10.5216/ree.v21.56571
  » https://doi.org/10.5216/ree.v21.56571
• 11. Pontes LG, Mello LF, Silva FH, Nunes AS, Ferrão CTGB, Peres EM. Neurogenic dysfunction of the lower urinary tract: construction and validation of an instrument for nursing consultation. Estima. 2022;20:e1822. doi: https://doi.org/10.30886/estima.v20.1225_IN
  » https://doi.org/10.30886/estima.v20.1225_IN
• 12. Jordão RRR, Sousa SMA, Fernandes FL, Lopes MVO, Mangueira SO, Silva GP, et al. Content validation of interrupted family processes nursing diagnosis. Acta Paul Enferm. 2022;35:eAPE01716. doi: https://doi.org/10.37689/acta-ape/2022AO0171666
  » https://doi.org/10.37689/acta-ape/2022AO0171666
• 13. Ferreira RC, Duran ECM. Clinical validation of nursing diagnosis “00085 Impaired Physical Mobility” in multiple traumas victims. Rev Latino Am Enfermagem. 2019;27:e3190. doi: https://doi.org/10.1590/1518-8345.2859.3190
  » https://doi.org/10.1590/1518-8345.2859.3190
• 14. Almeida MA, Lucena AF, Nomura ATG, Graeff M, Chies N, Pruinelli L. Development of a nursing diagnosis educational software program. Rev Gaúcha Enferm. 2021;42:e20190283. doi: https://doi.org/10.1590/1983-1447.2021.20190283
  » https://doi.org/10.1590/1983-1447.2021.20190283
• 15. Scaratti M, Johann GRP, Argenta C, Zanatta EA. Content and semantics validation of an application for adolescents with diabetes mellitus. Acta Paul Enferm. 2023;36:eAPE021031. doi: https://doi.org/10.37689/acta-ape/2023AO021031
  » https://doi.org/10.37689/acta-ape/2023AO021031
• 16. Coluci MZO, Alexandre NMC, Milani D. Construção de instrumentos de medida na área da saúde. Ciênc Saúde Colet. 2015;20:925-36. doi: https://doi.org/10.1590/1413-81232015203.04332013
  » https://doi.org/10.1590/1413-81232015203.04332013
• 17. Alexandre NMC, Coluci MCO. Validade de conteúdo nos processos de construção e adaptação de instrumentos de medidas. Ciênc Saúde Colet. 2011;16:3061-8. doi: https://doi.org/10.1590/S1413-81232011000800006
  » https://doi.org/10.1590/S1413-81232011000800006
• 18. Matus C. Política, planejamento e governo. Brasília, DF: Ipea; 1996.
• 19. Conselho Federal de Enfermagem (BR). Resolução Cofen nº 358 de 15 de outubro de 2009. Dispõe sobre a Sistematização da Assistência de Enfermagem e a implementação do Processo de Enfermagem em ambientes, públicos ou privados, em que ocorre o cuidado profissional de Enfermagem, e dá outras providências. Diário Oficial União. 2009 out 23 [cited 2024 Feb 11];146(203 Seção 1):179. Available from: https://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?data=23/10/2009&jornal=1&pagina=179&totalArquivos=184
  » https://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?data=23/10/2009&jornal=1&pagina=179&totalArquivos=184
• 20. Conselho Federal de Enfermagem (BR). Resolução Cofen nº 514/2016. Aprova o Guia de Recomendações para registros de enfermagem no prontuário do paciente. Brasília, DF: COFEN; 2016 [cited 2024 Feb 11]. Available from: http://www.cofen.gov.br/resolucao-cofen-no-05142016_41295.html
  » http://www.cofen.gov.br/resolucao-cofen-no-05142016_41295.html
• 21. Santana RM, Tahara ATS. Planejamento em enfermagem: aplicação do processo de enfermagem na prática administrativa. Ilhéus: Editus; 2008.
• 22. Matos FR, Rossini JC, Lopes RFF, Amaral JDHF. Translation, adaptation, and evidence of content validity of the Schema Mode Inventory. Psicol Teor Prat. 2020;22(2):39-59. doi: https://doi.org/10.5935/1980-6906/psicologia.v22n2p39-59
  » https://doi.org/10.5935/1980-6906/psicologia.v22n2p39-59
• 23. Balbim R, Krause C, Becker MF, Lima Neto VC, Cassiolato MM, Andrade CC. Metodologia de avaliação de resultados: o caso das intervenções do PAC urbanização de favelas. Rio de Janeiro: IPEA; 2013.
• 24. Yusoff MSB. ABC of content validation and content validity index calculation. Educ Med J. 2019;11(2):49-54. doi: https://doi.org/10.21315/eimj2019.11.2.6
  » https://doi.org/10.21315/eimj2019.11.2.6
• 25. Ferreira AP, Coelho KR, Schlosser TCM, Poveda VB, Silva LLT. Construction and validation of a booklet of perioperative orientation and patient safety. Rev Gaúcha Enferm. 2022;43:e20210175. doi: https://doi.org/10.1590/1983-1447.2022.20210175.pt
  » https://doi.org/10.1590/1983-1447.2022.20210175.pt
• 26. Aldrighi JD, Dalmolin A, Girardon-Perlini NMO, Lacerda MR, Trigueiro TH, Wall ML. Integrative approach to the development of situation specific theories: theoretical reflection. Texto Contexto Enferm. 2023;32:e20220255. doi: https://doi.org/10.1590/1980-265X-TCE-2022-0255en
  » https://doi.org/10.1590/1980-265X-TCE-2022-0255en
• 27. Taffner VBM, Pimentel RRS, Almeida DB, Freitas GF, Santos MJ. Nursing theories and models as theoretical references for Brazilian theses and dissertations: a bibliometric study. Rev Bras Enferm. 2022;75(4):e20210201. doi: https://doi.org/10.1590/0034-7167-2021-0201
  » https://doi.org/10.1590/0034-7167-2021-0201
• 28. Ferreira FMS, Silva FC, Natarelli TRP, Mello DF, Fonseca LMM. Child vaccination in animated infographic: technology for permanent education about the nursing process. Rev Esc Enferm USP. 2023;57:e20220423. doi: https://doi.org/10.1590/1980-220X-REEUSP-2022-0423en
  » https://doi.org/10.1590/1980-220X-REEUSP-2022-0423en
• 29. Michelon JM, Backes DS, Costenaro RGS, Ilha S, Lunardi VL, Zamberlan C. Nursing process directed to newborns in a usual risk maternity ward: nurses' perceptions. Texto Contexto Enferm. 2023;32:e20220197. doi: https://doi.org/10.1590/1980-265X-TCE-2022-0197pt
  » https://doi.org/10.1590/1980-265X-TCE-2022-0197pt
• 30. Mauro AD, Cucolo DF, Perroca MG. Nursing actions for continuity of care in primary health care: a validation study. Texto Contexto Enferm. 2023;32:e20230058. doi: https://doi.org/10.1590/1980-265X-TCE-2023-0058pt
  » https://doi.org/10.1590/1980-265X-TCE-2023-0058pt

Edited by

Associate editor:

Adriana Aparecida Paz

Editor-in-chief:

João Lucas Campos de Oliveira

Publication Dates

• Publication in this collection
  05 July 2024
• Date of issue
  2024

History

• Received
  19 Nov 2023
• Accepted
  06 Mar 2024