Contributions of representing the elements of nursing practice in the ISO 18.104:2023 standard: a theoretical study

OBJECTIVE

To reflect on the contributions of representing nursing practice elements in the ISO 18.104:2023 standard.

METHOD

This is a theoretical study with standard analysis. Categorical structures were described to represent nursing practice in terminological systems and contributions identified in the parts of the version were analyzed.

RESULTS

There is innovation in the inclusion of nurse sensitive outcomes, nursing action, nursing diagnosis explanation as an indicator of nursing service demand and complexity of care, representation of concepts through mental maps and suggestion of use of restriction models for nursing actions. It describes that the Nursing Process is constituted by nursing diagnosis, nursing action and nurse sensitive outcomes.

FINAL CONSIDERATIONS

Indicating a nursing diagnosis as an indicator will bring benefits for knowledge production and decision-making. Although care outcomes are not exclusive responses to nursing action, the modifiable attributes of a nursing diagnosis generate knowledge about clinical practice, nursing action effectiveness and subjects of care' health state. There is coherence in understanding the Nursing Process concept evolution.

Geropalliative Caring Model analysis and assessment according to Fawcett's criteria

OBJECTIVES

To analyze and assess Lee Geropaliative Caring Model according to Fawcett's criteria.

METHOD

A theoretical-reflective study about the Geropaliative Caring Model. The analysis resulted in a detailed review of the scope, context and content of a situation-specific theory, in order to determine aspects related to nursing practice and research, and assessment addressed the concrete concepts developed in theory, their significance, internal consistency, parsimony, testability and empirical and pragmatic adequacy in nursing as a discipline.

RESULTS

Based on the analysis, a situation-specific theory was used based on the science of care and aimed at caring for older adults undergoing palliation and their families, structured into four fields, namely: (1) aligning care; (2) keeping safe; (3) comforting body/mind/spirit; and (4) facilitating transitions.

FINAL CONSIDERATIONS

The analyzed and assessed theory leads to a structure that includes well-defined, delimited and interrelated concepts, based on the science of care as a grand theory that allowed Geropaliative Care Model derivation.

Nursing microtheory in the prevention of delirium in older adult in the intensive care unit

OBJECTIVE

to describe a microtheory for nursing care in the prevention of delirium in older adult in the intensive care unit.

METHOD

prescriptive theoretical research, based on substruction. Roy's Adaptation Model constructs were deduced and data from the phenomenon of nursing care in the prevention of delirium in older adult in intensive care were induced, based on an integrative literature review.

RESULTS

the microtheory has a theoretical and operational system and a model of care. In the theoretical system, Roy's focal and contextual stimulus constructs were used. From them, the concepts of focal and contextual care and the variable adaptive response to prevention were elaborated. From the relational statements, four axioms, two postulates, eight propositions and an epistemic assumption were elaborated.

TWO EMPIRICAL INDICATORS WERE ESTABLISHED IN THE OPERATING SYSTEM

the Confusion Assessment Method for Intensive Care Units and the demographic/clinical history of the older adult. Subsequently, two transformational statements, four hypotheses and the model of care represented in figure were produced.

CONCLUSION

the microtheory produced prescribes care in the prevention of delirium in older adult in intensive care, through a construct of interest to nursing, and allows interceptions for the development of instruments that guide nursing activities.

Theoretical, Conceptual, and Operational Aspects in Simulation Training With Rapid Cycle Deliberate Practice: An Integrative Review

SUMMARY STATEMENT

An integrative review following Whittemore and Knafl's 5-stage approach (problem identification, literature search, data evaluation, data analysis, and presentation) was conducted to synthesize the evidence on the theoretical, conceptual, and operational aspects of simulation training with rapid cycle deliberate practice (RCDP). After the literature search, 2 reviewers independently read and critically evaluated primary studies using the eligibility criteria. A third more experienced reviewer solved disagreements between the reviewers.This review included 31 articles. Eight themes were identified and grouped into 2 pre-established categories: theoretical/conceptual and operational aspects. The first category had the following 3 themes: definition of RCDP, concepts related to the principles of RCDP, and theories underpinning RCDP. The second category had the following 5 themes: total training time, number of participants in the training, training system, first scenario without intervention, and progressive difficulty. This review showed that knowledge about RCDP is still under construction. As a new simulation strategy, there are some theoretical, conceptual, and operational differences in the studies applying RCDP interventions as simulation training.

Architectural accessibility and perception of falls of elderly people in the peridomicile: mixed method

OBJECTIVE

To describe contents, structure and origin of social representations about falls by elderly people, the peridomiciliary structural conditions that predispose to falls, and to relate the implications of these empirical evidence on the routine of the elderly in the architectural context.

METHOD

Convergent mixed method by triangulation. Qualitative approaches(structural, n=195 and procedural, n=40of the Theory of Social Representations) and quantitative (descriptive sectional, n=183) were used. Elderly people enrolled in primary care were interviewed at home in 2018. Analysis techniques: categorical-thematic, prototypical, statistical, and deductive according to Leininger.

RESULTS

Categories of analysis: 1) Peridomicile: fall scenario and 2) Aging and vulnerability: risk of falls in peridomicile. The following environmental characteristics were precursors to falls: uneven floors, holes, unevenness and objects in the pathway. Feelings and behaviors allocated in the possible central core are associated, justifying falls, and determining their causes.

CONCLUSION

There was an association between the peridomiciliary architectural environment and the predictive characteristics of the risk of falls.

Systematization of Nursing Care: how did the concept mature?

OBJECTIVES

to analyze the Systematization of Nursing Care conceptual maturation from the perspective of pragmatic utility.

METHODS

a concept analysis study. The stages were: select the concept; elaborate analytical questions; comprehensively review the literature; and determine concept structural components. Sixty-one documents were analyzed after a search carried out until October 2019.

RESULTS

four temporal periods of contextual changes have occurred since the emergence of ideas of a systematization in the 1960s. This first lasted until 1990. It was followed by those from 1990 to 2002, from 2002 to 2009 and from 2009 onwards. Partial conceptual maturity was identified, operationalization over the years, based on multiple definitions, and, currently, a concept of Systematization of Nursing Care with managerial and organizational attributes.

CONCLUSIONS

the concept of Systematization of Nursing Care is partially mature, presents multiple definitions, being operationalized in uncertain connections with other concepts.

Effect of rapid cycle deliberate practice in peripheral intravenous catheters insertion training: A simulation experimental study

AIM

to compare the effect of rapid cycle deliberate practice simulation training with skill-training simulation on peripheral intravenous catheter insertion for Licensed Practical Nurses.

BACKGROUND

The use of peripheral intravenous catheters is associated with high rates of complications, although it is widely used in clinical practice. Training strategies to ensure good performance can minimize the risks inherent to this procedure.

DESIGN

A randomized simulation experimental pre-post interventional study.

METHODS

Sixty participants were allocated to intervention (n = 30) or control (n = 30) groups. Participants allocated to the intervention group were trained through the Rapid cycle deliberate practice simulation strategy, while participants in the control group were trained through the skill-training simulation strategy. A pre-test was applied before any intervention and a post-test after intervention. The primary outcome was the performance in the peripheral intravenous catheter insertion skill. The comparison of correct performance in the tests was analyzed intergroup and intragroup. The effect size of the interventions was also analyzed. The t-Student and Mann-Whitney tests compared the difference between the groups. The training effect was calculated by Cohen's dm and Glass's Δ measures.

RESULTS

Performance between the pre-post-test increased from 59.4% to 96% (p < 0.001) in the intervention group and from 57.8% to 93.5% in the control group (p < 0001). There was no statistical difference between the groups after intervention (p = 0225). Cohen's dm measurement was 2.95 and 3.59 in the control and intervention groups, respectively.

CONCLUSIONS

The rapid cycle deliberate practice simulation strategy resulted in Licensed Practical Nurses' performance improvements in peripheral intravenous catheter insertion, evidenced by the increase of correct performance actions in the post-test compared to the pre-test. However, with no statistical difference compared to the skill-training simulation strategy.

Body image of women during breastfeeding: analysis supported by nursing theory

OBJECTIVE

To describe and interpret a woman's perception of her body image during the breastfeeding process.

METHOD

Descriptive qualitative study conducted at a university hospital in the Southeast region, Brazil. Forty-three puerperal women who were breastfeeding were interviewed. The interviews were submitted to lexical analysis using the IRAMUTEQ software and interpreted based on the Interactive Theory of Breastfeeding.

RESULTS

Women report dissatisfaction with changes in body image during breastfeeding. But they also value and want to keep breastfeeding because of the benefits for the child. Finally, several women express the desire to perform plastic surgery in the future because of these body changes.

CONCLUSION

The woman's perception of her body image as satisfactory/unsatisfactory indicates that body changes cover the breastfeeding process with feelings of ambiguity.Body changes are perceived by women in a personal, subjective and complex way.

Guide for Systematization of Care and Nursing Process: educational technology for professional practice

OBJECTIVE

to elaborate and validate the content of a digital guide educational technology on Systematization of Nursing Care and Nursing Process.

METHODS

applied research of technological development, developed between 2020 and 2021, in three steps. First, a scoping review was carried out to elaborate the content. In the second step, the content was validated with 46 nurse judges selected for convenience. The minimum criterion of agreement among judges was 80%. The third step consisted of content organization and layout.

RESULTS

the guide content was elaborated from the Federal Nursing Council legislation, scientific articles and textbooks. Content was considered appropriate, relevant and organized by judges.

FINAL CONSIDERATIONS

the digital guide is an alternative that can contribute to the NP execution and implementation, supporting the planning and implementation of actions for quality of care.

Escala Interativa de Amamentação: avaliação da confiabilidade

Resumo Objetivo avaliar a confiabilidade da Escala Interativa de Amamentação. Método estudo metodológico, que seguiu a terceira etapa do método de Pasquali para elaboração de escalas, desenvolvido com 216 puérperas, em hospital universitário da região Sudeste do Brasil. Para avaliação da confiabilidade, foram utilizados o percentual de concordância (pa) acima de 80%, o Kappa ponderado (Kp), a second-order agreement coefficient (AC2) de Gwet e o alfa de Cronbach. Resultados o percentual de concordância dos itens foi de 83,33%; o valor global do alfa de Cronbach foi de 0,67; o coeficiente AC2 com ponderações quadrática e linear obteve a confiabilidade quase perfeita. Conclusão e implicação para a prática a avaliação da confiabilidade da Escala Interativa de Amamentação foi alta, e foi confirmada pelos resultados que asseguram a qualidade do instrumento na população estudada, mostrando-se um instrumento confiável e válido para avaliar os fatores que interferem na interação mãe-filho durante a amamentação.

Can support surfaces characteristics influence high-quality chest compression? manikin experiment with a mechanical device

BACKGROUND

Support surfaces variables, such as size, material, and density, can determine chest compression depth in cardiopulmonary resuscitation.

OBJECTIVE

to analyze the force required to do a high-quality chest compression concerning different surfaces in CPR.

METHOD

This experimental study was developed using a Little Anne manikin and a mechanical device to perform chest compressions. Nine sets of surfaces were tested and compared to a control.

RESULTS

230 experimental tests were done in sets of bed or stretcher + mattress and presence or absence of different backboards. In the control condition, the average force to reach 5 cm of depth was 42.14±0.97 (kgf). Set 9, compatible with a narrow stretcher with a thin mattress, had the best surfaces to reach recommended depth, with or without a backboard. All other sets required significantly more force for high-quality chest compression. Regression analysis confirms that backboard size is not significant for the force for high-quality chest compression.

CONCLUSION

There is an association of dimensions and types of beds or stretchers and mattresses with a force increase. Type and dimensions of the backboard are not relevant for the force required, regardless of the characteristics of the set of the bed or stretcher and mattress.

"Readiness for enhanced healthy aging" nursing diagnosis: Content validation by experts

PURPOSE

To validate the content nursing diagnosis "Readiness for enhanced healthy aging."

METHODS

Descriptive, methodological study of diagnostic content validation, using the Fehring model. The sample consisted of 74 nurses experts in gerontology, with knowledge in NANDA-I nursing diagnoses.

FINDINGS

The title, one definition, and the three defining characteristics proposed for the diagnosis were validated, as well as the suggestion of domain and location class in NANDA-I Taxonomy II. The Diagnostic Content Validity Index was 0.81.

CONCLUSIONS

The validation of the diagnostic content by experts was fundamental for adequacy of the elements of the proposed diagnosis, which supported the elaboration of the diagnostic framework for submission to the NANDA-I taxonomy.

IMPLICATION FOR NURSING PRACTICE

The diagnosis "Readiness for enhanced healthy aging" can help nurses understand the phenomenon of "Healthy Aging" and, consequently, will support the planning and implementation of interventions aimed at promoting the health of the elderly population and those in the aging process. In addition, this diagnosis will offer nurses the opportunity to rethink health promotion strategies in their care plan, making a commitment to the population regarding the promotion of healthy aging, as recommended by the Word Health Organization.

Interactive Breastfeeding Scale: reliability assessment

Abstract Objective to assess the Interactive Breastfeeding Scale reliability. Method a methodological study that followed the third stage of Pasquali’s method for the elaboration of scales, carried out with 216 postpartum women at a university hospital in southeastern Brazil. To assess reliability, percentage of agreement (pa) above 80%, the weighted Kappa (Kp), Gwet’s second-order agreement coefficient (AC2) and Cronbach’s alpha were used. Results the percentage of agreement was 83.33%; the overall Cronbach’s alpha value was 0.67; the AC2 coefficient with quadratic and linear weights obtained near-perfect reliability. Conclusion and implication for practice the Interactive Breastfeeding Scale reliability assessment was high, and it was confirmed by the results that ensure instrument quality in the population studied, proving to be a reliable and valid instrument to assess factors that interfere in the mother-child interaction while breastfeeding.

Toward a theorizing strategy with components of terminologies, classifications, and nursing theories

PURPOSE

This article describes a theorizing strategy that integrates the components of classifications or terminologies with elements of grand or middle-range theories.

METHODS

The source of metatheoretical data to support the strategy was the levels of theories by Dickoff et al. (1968). Terminological data sources were professional classifications and terminologies.

FINDINGS

The authors synthesized data and philosophical, metatheoretical, theoretical, and terminological knowledge from primary sources on the subject to construct arguments and demonstrate suitable links.

CONCLUSIONS

The proposal presented in this article of a strategy for building theories integrates theories and classifications or standardized nomenclatures. It applies levels of theorization: scrutiny of phenomena, description, conceptualization, naming, relationship, modeling, and operationalization to achieve higher levels of explanatory, predictive, and prescriptive properties on generated theory.

IMPLICATIONS FOR NURSING PRACTICE

The implications for practice and research are connected to the theorizing strategy proposed in this article. We assume that using professional language at all levels of theorization can ensure that the concepts generated are closer to clinical practice.

Analysis of the concept of cardiovascular risk: contributions to nursing practice

OBJECTIVES

to analyze the concept of cardiovascular risk to support nursing practice.

METHODS

this is an analysis to define the concept of cardiovascular risk, through the use of eight steps of Walker's and Avant's framework, using a literature review in indexed scientific journals.

RESULTS

cardiovascular risk is defined in a broad and original way as a context of health and nursing care that makes it possible to identify modifiable (cardiometabolic, behavioral, psychosocial, cultural and occupational) and non-modifiable (biological) risk factors for cardiovascular diseases that act as early and interrelated markers, of multiple and heterogeneous etiology, predisposing to cardiovascular vulnerability.

CONCLUSIONS

with the analysis and definition of the concept of cardiovascular risk, we realized that it will be possible to base nursing practice, with implications in clinical practice for identifying and reducing risk factors for cardiovascular diseases, with nursing relevance in the care of these subjects.

Nursing theories developed to meet children's needs: a scoping review

OBJECTIVE

To map the nursing theories developed to meet children's needs.

METHOD

The JBI methodology and the PRISMA guided this scoping review. The search took place between October and November 2021, based on the PCC mnemonic: P (Population) - a child aged 0 to 9 years; C (Concept) - nursing theories; C (Context) - nursing.

RESULTS

We identified 2,242 publications and selected 21 manuscripts consisting of nursing theories to meet children's feeding needs, child pain, a child with asthma, diabetes, obesity, epilepsy, Congenital Zika Syndrome, autism spectrum disorder; theory for care in Intensive Care Units; health promotion to premature babies; procedures in Intensive Care Units; theory for nursing diagnosis ineffective breathing pattern in children with congenital heart disease; sleep associated with child development; parent-child interaction; nurse-child relationship; and child's consultation.

CONCLUSION

The nursing theories mapped have the potential to outline the course of nursing care to children's needs highlighted in the studies that made up the sample.

Radiodermatitis: severity, predictive factors and discontinuation of radiotherapy in patients with anal and rectal cancer

OBJECTIVE

to determine the prevalence of radiodermatitis, severity grades and predictive factors of its occurrence in patients with anal and rectal cancer followed up by the nursing consultation, and to analyze the association of severity grades of radiodermatitis with temporary radiotherapy interruption.

METHOD

a quantitative, cross-sectional and retrospective study, carried out with 112 medical records of patients with anal and rectal cancer undergoing curative radiotherapy followed up in the nursing consultation. Data were collected using a form and analyzed using analytical and inferential statistics.

RESULTS

99.1% of patients had radiodermatitis, 34.8% of which were severe. The predictive factors were female sex, age greater than 65 years, anal canal tumor, treatment with cobalt device and IMRT technique. Treatment interruption occurred in 13% of patients, associated with severe radiodermatitis.

CONCLUSION

there was a high prevalence of radiodermatitis, mainly severe, which resulted in treatment interruption.

Theoretical Study Theory of professional bonds: description and theoretical analysis based on the Meleis' model with Delphi strategy

The objective of this study was to evaluate the Theory of Professional Bonds from the description and analysis steps of Meleis' theory evaluation model. This is a theoretical, analytical, and philosophical study, with the collection of manuscripts through literature review to deepen knowledge regarding the origin, the theoretical and philosophical frameworks, and the practical application of the Theory of Professional Bonds. The study was developed in two steps: procedures for the evaluation using the model proposed by Meleis' and procedures for validation of the evaluation using the Delphi strategy and the Likert scale. Descriptive-reflective analysis involves an impartial and detailed examination of the theory, and it is possible to define the scope for a middle-range theory based on Leontiev's Activity Theory. Concepts are defined, delimited and interrelated. It is possible to transcend its applicability from the nursing team to the interdisciplinary team. The theory evaluation advanced by reaffirming the importance of theory to practice and identifying potential for theoretical development, contributing to the elaboration of an unprecedented guideline for theoretical nursing studies.

Aprendizagem do raciocínio diagnóstico de enfermagem de estudantes por meio de tecnologias educacionais: revisão integrativa

Objetivo: Analisar as habilidades e experiências desenvolvidas a partir do uso de tecnologias educacionais no raciocínio diagnóstico de enfermagem de estudantes de graduação. Método: Revisão integrativa da literatura realizada em abril de 2020, por meio do acesso online a sete bases de dados, não sendo estabelecido um recorte temporal. Termos de busca como “estudantes de enfermagem”, “tecnologia educacional” e “diagnóstico de enfermagem” foram incorporados nas estratégias de busca. Resultados: Em um universo de 332 títulos e resumos consultados, foram selecionados 21 artigos que respondiam de forma integral à pergunta de pesquisa. Foram identificadas 13 tecnologias educacionais presenciais e 8 virtuais que forneceram habilidades metacognitivas, cognitivas, práticas e experiências do tipo afetivas e motivacionais aos acadêmicos de enfermagem. Conclusão: A maioria das tecnologias presenciais impactaram diretamente no raciocínio diagnóstico dos estudantes, enquanto as tecnologias virtuais contribuíram indiretamente para seu desenvolvimento.

Risk for Imbalanced Blood Glucose Pattern: Construct Analysis and Nursing Diagnosis Proposal

To identify a clinical judgment of susceptibility referring to the development of glycemic fluctuations in adults with Diabetes Mellitus undergoing treatment. Theoretical study with construct analysis. The exploration of the phenomena of glycemic variations provided clues for the description of the blood glucose pattern construct and the proposal of a new risk Nursing diagnosis as a judgment of susceptibility to the balance of this pattern. The risk factors for "Risk for Imbalanced Blood Glucose Pattern" are cognitive dysfunction; excessive alcohol consumption; excessive daily exercise; inadequate follow through with treatment regimen; increased frequency of self-monitoring of blood glucose; inadequate knowledge of disease process; inadequate management of amount of food; inadequate regularity of meal consumption; obesity; overweight; smoking; underweight. The elaboration of "Risk for Imbalanced Blood Glucose Pattern" Nursing diagnosis contributes to the advancement in the Nursing classifications and to the elaboration of planning actions and specific interventions.

PUNÇÃO VENOSA PERIFÉRICA E CONTRASTE NOS EXAMES RADIOLÓGICOS: REPRESENTAÇÕES SOCIAIS ANCORADAS NOS ESTRESSORES DE NEUMAN

RESUMO Objetivo: discutir as representações sociais sobre a punção venosa periférica e o uso de meios de contraste de pessoas submetidas a exames radiológicos, referenciando-se no conceito de estressores. Método: pesquisa qualitativa, delineada na abordagem processual da Teoria das Representações Sociais, realizada com 57 usuários submetidos a exames de Tomografia Computadorizada e Ressonância Magnética em um Hospital Universitário de Juiz de Fora, Minas Gerais, Brasil. Realizaram-se entrevistas individuais em profundidade desencadeadas por questões norteadoras em janeiro de 2019. Os conteúdos das entrevistas foram transcritos na íntegra e realizou-se análise de conteúdo em três etapas (pré-análise, exploração do material e tratamento/interpretação dos resultados). A análise temático-categorial estabelecida a partir das dimensões e origens representacionais possibilitou a discussão dos achados ancorada nos conceitos de estressores, permitindo a identificação de três categorias baseadas nos estressores intrapessoais, interpessoais e transpessoais. Resultados: a punção e o exame foram representados pelas vivências individuais, grupais, com profissionais e ambiente terapêutico, classificados nas categorias: itinerário e concepções sobre punção e exames contrastados, com base em estressores intrapessoais; relações compartilhadas sobre a punção e o exame, fundamentadas em estressores interpessoais e vivências no ambiente terapêutico de um serviço de diagnóstico por imagem, a partir dos estressores transpessoais. Conclusão: as representações sociais foram significadas por exame, resultado e impactos na vida, retratando estressores alicerçados em imagens/sentimentos de dúvida e comportamentos positivos justificados racionalmente, que explicitam respostas humanas a conteúdos reificados, possibilitando a reestruturação do cuidado em saúde e em enfermagem.

PERIPHERAL VENOUS PUNCTURE AND CONTRAST IN RADIOLOGICAL EXAMS: SOCIAL REPRESENTATIONS ANCHORED IN NEUMAN’S STRESSORS

ABSTRACT Objective: to discuss the social representations about peripheral venipuncture and the use of contrast media of people submitted to radiological examinations, referring to stressor concept. Method: this is qualitative research, outlined in the procedural approach of the Social Representation Theory, carried out with 57 users undergoing computed tomography and magnetic resonance imaging at a university hospital in Juiz de Fora, Minas Gerais, Brazil. In-depth individual interviews triggered by guiding questions were conducted in January 2019. The contents of the interviews were fully transcribed and content analysis was carried out in three stages (pre-analysis, material exploration and treatment/interpretation of results). We established thematic analysis based on the dimensions and representational origins, which made it possible to discuss the findings anchored in the concepts of stressors, allowing the identification of three categories based on intrapersonal, interpersonal and transpersonal stressors. Results: puncture and examination were represented by individual, group, professional and therapeutic environment experiences, classified into the following categories: itinerary and conceptions on puncture and contrasted examinations based on intrapersonal stressors; shared relationships on puncture and examination, based on interpersonal stressors; and experiences in the therapeutic environment of a diagnostic imaging service, based on transpersonal stressors. Conclusion: the social representations were signified by examination, results and impacts on life, portraying stressors based on images/feelings of doubt and positive behaviors rationally justified, which explain human responses to reified content, enabling the restructuring of health care and nursing.

Metacognição em um jogo educativo orientado pelo processo de enfermagem sobre distúrbios eletrolíticos

Resumo Objetivos Descrever os eventos metacognitivos contidos nos relatos de alunos de enfermagem após participação em jogo educativo e identificar as operações metacognitivas presentes nos relatos de alunos de enfermagem após participação no jogo educativo. Método Estudo qualitativo para a compreensão de eventos e processos metacognitivos de vinte e seis estudantes engajados na solução de um caso de distúrbios eletrolíticos, orientados pelo processo de enfermagem. Dados coletados por entrevista semiestruturada. Análise de conteúdo com categorias teóricas da metacognição para procedimentos dedutivos e classificatórios. Resultados Foram identificadas quinze características do processo e do controle durante o jogo, com operações metacognitivas a partir de eventos metacognitivos presentes nas falas dos participantes do jogo. As fases de antecipação, de controle da performance e de autorregulação reflexiva foram utilizadas para classificar as quinze características emergentes da tarefa. Conclusão A participação em um jogo educacional orientado à aprendizagem do processo de enfermagem pode evidenciar descrições de eventos metacognitivos, clarificando processos mentais. Implicações para a prática Conhecer as características de um trajeto metacognitivo mais comum pode facilitar a atuação do professor como mediador e facilitador da aprendizagem em aspectos específicos.

Nursing Process in the Brazilian context: reflection on its concept and legislation

ABSTRACT Objectives: to reflect on the global understanding of the Nursing Process concept, with emphasis on the Brazilian context. Methods: a reflection article, aligned with the vision and expertise of researchers who are members of the Nursing Process Research Network. Results: the reflection is presented in two main topics: The evolution of Systematization of Nursing Care X Nursing Process concepts and its consonance with national and international practices, and Brazilian legislation; The Nursing Process concept realignment in Brazilian legislation in line with current care, teaching and research practices. Final Considerations: the reflections were oriented to the Nursing Process’ conceptual, normative and legal issues, including elements of its historical evolution, and, with that, pointed to the need to modify the Brazilian regulation on the Nursing Process.

Radiodermatite: severidade, fatores preditivos e interrupção da radioterapia em pacientes com câncer anal e de reto

RESUMO Objetivo: determinar a prevalência da radiodermatite, os graus de severidade e os fatores preditivos da sua ocorrência em pacientes com câncer de canal anal e reto acompanhados pela consulta de enfermagem, e analisar a associação dos graus de severidade da radiodermatite com a interrupção temporária da radioterapia. Método: pesquisa quantitativa, seccional e retrospectiva, realizada com 112 prontuários de pacientes com câncer de canal anal e reto submetidos à radioterapia curativa acompanhados na consulta de enfermagem. Dados foram coletados por formulário e analisados empregando-se estatística analítica e inferencial. Resultados: 99,1% dos pacientes apresentaram radiodermatite, sendo 34,8% graus severos. Os fatores preditivos foram sexo feminino, idade maior que 65 anos, tumor de canal anal, tratamento com aparelho de cobalto e técnica IMRT. A interrupção do tratamento ocorreu em 13% dos pacientes, associada à radiodermatite severa. Conclusão: houve alta prevalência de radiodermatite, principalmente grau severo, que resultou em interrupção do tratamento.

Análise do conceito de risco cardiovascular: contribuições para a prática de enfermagem

RESUMO Objetivos: analisar o conceito de risco cardiovascular para fundamentar a prática de enfermagem. Métodos: trata-se de uma análise para definição do conceito de risco cardiovascular, por meio da utilização de oito etapas do referencial de Walker e Avant, utilizando uma revisão da literatura em periódicos científicos indexados. Resultados: define-se o risco cardiovascular de forma ampla e original como contexto de saúde e de cuidado de enfermagem que permite identificar fatores de risco para doenças cardiovasculares modificáveis (cardiometabólicos, comportamentais, psicossociais, culturais e laborais) e não modificáveis (biológicos), que atuam como marcadores precoces e inter-relacionados, de etiologia múltipla e heterogênea, predispondo à vulnerabilidade cardiovascular. Conclusões: com a análise e definição do conceito de risco cardiovascular, percebemos que será possível fundamentar a prática de enfermagem, com implicações na prática clínica para identificação e redução dos fatores de risco para doenças cardiovasculares, com protagonismo da enfermagem no cuidado desses sujeitos.

Healthy aging promotion model referenced in Nola Pender's theory

OBJECTIVES

to model the process of promoting healthy aging from the conceptual analysis proposed by Walker and Avant and Nola Pender's Health Promotion Model.

METHODS

this is a descriptive and theoretical study, with a qualitative approach. Elements resulting from conceptual analysis were used to model a healthy aging promotion process based on Nola Pender's Health Promotion Model.

RESULTS

in conceptual analysis, seven antecedents, seven attributes and three consequences of the concept of healthy aging were identified.

FINAL CONSIDERATIONS

the proposed Health Promotion Model represents a structure that in an instrumental way can guide the nursing process application in gerontological clinical practice. This can guide nurses in identifying diagnoses, establishing outcomes and implementing interventions aimed at promoting the elderly's health.

Compromised end-of-life syndrome: Concept development from the condition of adults and older adults in palliative care

PURPOSE

This study aimed to develop the nursing diagnosis concept "compromised end-of-life syndrome" in palliative care.

METHODS

The authors used the integrative strategy by Meleis to develop the concept in this study and identifying clinical indicators from a literature review. For data organization, we applied the Preferred Reporting Items for Systematic Reviews and Metanalysis (PRISMA).

FINDINGS

Some clusters of unpleasant signs and symptoms in palliative care patients at the end of life, such as pain, dyspnea, depression, constipation, and anxiety, were identified. Through conceptualization, the authors propose a new nursing diagnosis, "compromised end-of-life syndrome." The manuscript includes a model case of a patient with nursing diagnosis syndrome as a clinical example.

CONCLUSIONS

Simultaneous patterns of signs and symptoms present in the literature reinforce the utility of the proposition of end-of-life syndrome as a nursing diagnostic construct.

IMPLICATIONS FOR NURSING PRACTICE

The concept development related to patients' unpleasant signs and symptoms critically ill at palliative care supports the proposition of a new nursing diagnosis relevant to selecting adequate nursing interventions and nursing outcomes. Some clusters of unpleasant signs and symptoms in palliative care patients at the end of life, such as pain, dyspnea, depression, constipation, and anxiety were identified. Conceptualization was used to propose a new nursing diagnosis, "compromised end-of-life syndrome." A model case of a patient with nursing diagnosis syndrome is described as a clinical example.

CONCLUSION

Simultaneous patterns of signs and symptoms present in the literature reinforce the utility of the proposition of end-of-life syndrome as nursing diagnostic construct.

IMPLICATIONS FOR NURSING PRACTICE

The concept development related to patients' unpleasant signs and symptoms critically ill at palliative care supports the proposition of a new nursing diagnosis relevant to selecting adequate nursing interventions and nursing outcomes.

Medium reach theory for nursing in cardiovascular rehabilitation

OBJECTIVES

to describe a medium-range nursing theory for the cardiovascular rehabilitation process.

METHODS

theoretical development study, addressing the elaboration of medium-range theory, based on Roy's Adaptation Model, which combined theoretical deduction with induction strategies, based on literature review and concept analysis.

RESULTS

the Medium-Range Theory for Nursing in Cardiovascular Rehabilitation presents eleven concepts and respective definitions, organized in relationships that represent elements, through modeling and image representation. Theoretical assumptions and propositions are presented.

FINAL CONSIDERATIONS

the theory presented aims to contribute to the description of the cardiovascular rehabilitation process from the perspective of the adaptation of the person, family and groups, as well as to impact the nursing care implemented to patients in the process. The procedures advanced from conceptualization to operationalization, through the production of theoretical propositions that will guide future theoretical testing.

Home fall of elderly people: implications of stressors and representations in the COVID-19 context

OBJECTIVES

To describe personal conditions and home structure that predisposes the elderly to the risk of falling, in the perspective of Neuman's stressors; to describe the content, structure and origin of social representations about falling at home by elderly people; and conjecture the implications of this empirical evidence on the daily lives of the elderly in the context of the pandemic caused by COVID-19.

METHOD

Mixed method with concomitant triangulation (January-July/2017), qualitative design (structural and procedural approaches to the Social Representations Theory) and quantitative (sectional) approaching elderly people ≥65 years.

RESULTS

Environmental factors were identified for falling at home, fear of activities of daily living and loss of visual acuity. Feelings and behaviors mentioned in the possible central nucleus justified the modulation of behaviors. Analysis categories: 1) Representation of the (in)adaptability of the home environment; 2) Representation and overcoming limitations arising from weaknesses.

CONCLUSION

It was possible to produce conjectures based on empirical evidence in the current situation in the pandemic's dynamics.

Risk factors for hyperglycemia and hypoglycemia in adults with pharmacologically treated type 2 diabetes mellitus: a quantitative systematic review protocol

OBJECTIVE

The objective of this review is to identify and synthesize the risk factors for hyperglycemia or hypoglycemia in adults with pharmacologically treated type 2 diabetes mellitus in any scenarios and environments for health care.

INTRODUCTION

Studies around the world have investigated which factors are associated with episodes of alteration of blood glucose level. It is through the characterization of these factors that nurses can plan and intervene accurately in the control of serum glucose levels in people with diabetes.

INCLUSION CRITERIA

This review will include studies conducted among adults with pharmacologically treated type 2 diabetes mellitus in any scenarios and environments for health care. Studies should focus on risk factors for the variation of fasting glycemic levels lower than 3.9 mmol/L and higher than 7.21 mmol/L, as well as postprandial glycemic levels lower than 3.9 mmol/L and higher than 10 mmol/L.

METHODS

Databases to be searched include MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, Scopus, LILACS, and ScienceDirect. Following the search, titles and abstracts will be screened by two independent reviewers for assessment against the inclusion criteria for the review. The full text of selected citations will be assessed in detail against the inclusion criteria, and studies selected for retrieval will be assessed by two independent reviewers for methodological validity using JBI critical appraisal tools. Studies will not be excluded based on their quality assessment. Data will be extracted using the standardized data extraction tools. Quantitative data will, where possible, be pooled in statistical meta-analysis.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO (CRD42019134755).

Guideline for incorporating the Delphi method in the evaluation of nursing theories

Objective:

to describe a guideline for the use of the Delphi method to evaluate nursing theories, from the perspective of internal validation.

Method:

a methodological study, targeted at the development of a guideline for the use of the Delphi method in the evaluation of nursing theories.

Results:

the Delphi method, principles of collective wisdom and levels of proficiency are used in the production of a guideline for organizing, searching, selecting and coordinating the activities of theoretical evaluators in teams. It distinguishes three phases for the theoretical evaluation process: Preparatory Phase (PP); Intermediate Phase (IP) and Theory Evaluation (TE) phase, incorporating Delphi-type selection procedures; search, selection and classification of judges/evaluators for the theory; definition of criteria for carrying out rounds and maintenance or removal of units of the theory evaluated.

Conclusion:

the developed guideline was able to adapt the elements of the Delphi method as a favorable strategy for the internal validation of nursing theories.

Análise simultânea dos conceitos de ansiedade e medo: contribuições para os diagnósticos de enfermagem

Resumo Objetivos Realizar a análise simultânea dos conceitos de ansiedade e medo. Método Análise simultânea de conceitos com base nas nove etapas propostas por Haase, Leidy, Coward, Britt e Penn. Resultados 43 artigos foram incluídos a partir de uma busca em cinco bases de dados. 51 atributos, 26 antecedentes e 10 consequentes foram identificados a partir da análise destes conceitos. Esta análise revelou que a ansiedade e o medo são conceitos subjetivos, multidimensionais e com altos graus de abstração. Conclusão A análise simultânea da ansiedade e do medo possibilitou o refinamento destes diagnósticos e a proposição de modificações em seus componentes. Implicações para a prática A análise destes conceitos possibilitará a identificação precisa destes fenômenos na prática clínica, proporcionando maior acurácia diagnóstica.

CONSTRUÇÃO DE DEFINIÇÕES OPERACIONAIS EM METACOGNIÇÃO

RESUMO Desde a década de 70 a metacognição vem sendo entendida como “conhecimento e cognição sobre fenômenos cognitivos”. Sua conceituação, apesar disso, ainda se apresenta inespecífica, a maioria dos pesquisadores tende a negligenciar o estabelecimento de definições mais precisas sobre a metacognição. Assim, foi realizada uma revisão narrativa, com enviesamento intencional orientado para a produção de definições operacionais aplicáveis ao processo de aprendizagem, de modo a permitir operar as ações de descrição, discriminação entre os diferentes fenômenos metacognitivos, sua classificação e interpretação de significados. A taxonomia aqui apresentada consta de 03 domínios (Habilidade, Experiência e Conhecimento Metacognitivos), trazendo 36 definições operacionais de termos metacognitivos.

Impacto das superfícies de compressão na massagem cardíaca durante a reanimação cardiopulmonar: uma revisão integrativa

Resumo Objetivo sintetizar as evidências disponíveis na literatura sobre os tipos de superfícies de compressão utilizadas na RCP e analisar quais características das superfícies de compressão têm impacto na eficácia da compressão torácica durante a RCP. Método revisão integrativa da literatura, cujos critérios de seleção e inclusão foram: artigos completos, em inglês, português ou espanhol e que respondessem a seguinte questão de pesquisa: “Quais são as características das superfícies de compressão que têm impacto na eficácia das compressões torácicas durante a RCP?”. Realizada entre os meses de junho e julho de 2019. Resultados inclui-se 12 artigos de estudos experimentais, cuja extração de dados revelou 13 tipos diferentes de colchões. Em relação às pranchas, seis tamanhos diferentes foram relatados, com diferentes materiais. Constatou-se influências do tipo de superfície de compressão na força necessária para realizar as compressões torácicas. Conclusão as evidências apontam que colchões de maiores dimensões e com tecnologia para redução de pressão e camas mais largas apresentam impactos negativos na qualidade das compressões torácicas. Implicação para prática o conhecimento sobre a influência do tipo e características das superfícies de apoio na qualidade das compressões torácicas podem subsidiar profissionais na escolha e incorporação de tecnologias no ambiente hospitalar.

Development and validation of a technology for obstetric intraoperative care safety

OBJECTIVES

to develop and validate an obstetric surgical safety checklist for intraoperative care.

METHODS

this is a methodological study with two phases: integrative review in databases, using selection criteria and descriptors to synthesize the evidence and develop the checklist; checklist content validation, with 37 judges, who answered a Likert-type questionnaire. For analysis, a >85% content validation index was applied.

RESULTS

the checklist's first moment reached a 96.1 content validation index; the second moment, 95.5; the third moment, 98.9. Thus, the validation index of all verifying sections present in the three surgical moments was 97.1. Cronbach's Alpha value was 95.57%.

CONCLUSIONS

the checklist items were validated by judges, with improvement of some items and insertion of others.

Brazilian Nursing Process Research Network contributions for assistance in the COVID-19 pandemic

OBJECTIVE

to describe the theoretical construction process of nursing process support documents in COVID-19 care scenarios.

METHODS

an experience report of the joint activity of the Brazilian Nursing Process Research Network (Rede de Pesquisa em Processo de Enfermagem) composed of Higher Education and Health Institution researchers in Brazil.

RESULTS

five instruments were organized collectively, involving the elements of nursing practice (nursing diagnoses, outcomes and interventions) in assistance for community; for patients (with suspected or mild, moderate, and critical COVID-19 and residents in Nursing Homes); for nursing workers' health support, also subsidizing registration and documentation during the COVID-19 pandemic.

FINAL CONSIDERATIONS

valuing the phenomena manifested by families/communities, patients and health professionals is essential for early detection, intervention, and prevention of diseases.

Proposal of Nursing Diagnosis "Readiness for Enhanced Healthy Aging": A Concept Analysis

PURPOSE

To analyze the concept of healthy aging and propose the development of a nursing diagnosis METHODS: Concept analysis using the method proposed by Walker and Avant FINDINGS: Four bibliographic databases were searched, and 36 articles were included in the analysis. Seven antecedents, seven attributes, and three consequences for "healthy aging" were identified.

CONCLUSIONS

The concept analysis supported the development of the new nursing diagnosis "readiness for enhanced healthy aging," which can assist nurses in implementing actions aimed at promoting the health of older adults.

IMPLICATION FOR NURSING PRACTICE

The establishment of a nursing diagnosis may provide nurses the opportunity to implement interventions that promote the maintenance of functional and cognitive capacity, psychological and spiritual well-being, and social engagement, aiming at healthy aging with high quality of life.

Análise do conceito de conforto: contribuições para o diagnóstico de Disposição para Conforto melhorado

RESUMO Objetivos Analisar o conceito de conforto à luz do modelo de análise conceitual evolucionista de Rodgers e incorporar elementos da análise conceitual na estrutura do diagnóstico de enfermagem “Disposição para conforto melhorado” (00183). Métodos Estudo de análise de conceito com aplicação das sete etapas do modelo evolucionário de Rodgers, sendo orientado para a condução da fase 1 de validação do diagnóstico de enfermagem. O material para análise foi obtido com a estratégia de revisão integrativa da literatura. Resultados e discussão Apresenta-se perspectiva histórico-desenvolvimental do conceito de quatro períodos temporais. Evidencia atributos, antecedentes, consequentes, termos substitutos e definições conceituais obtidos da decomposição conceitual, utilizando-os para a atualização dos componentes da “Disposição para conforto melhorado” (00183). Conclusão e implicações para a prática A abordagem evolucionária de análise do conceito mostrou ser apropriada para clarificar o conceito de conforto, dela emergindo tanto uma perspectiva orientada para o bem-estar quanto para as alterações do desconforto. A análise do conceito de conforto no método evolucionário contribuiu para a atualização do diagnóstico de enfermagem em tela. Os resultados obtidos fornecem elementos para a realização de futuros estudos de validação diagnóstica por experts e de validação clínica o que impacta positivamente no uso da linguagem diagnóstica.

Social identity of transgender persons: concept analysis and proposition of nursing diagnoses

ABSTRACT Objective: To analyze the concept of social identity of transgender persons and develop nursing diagnoses related to it. Methods: A concept analysis according to the Walker and Avant model. A scope review was carried out with a search of eight databases, a portal and two information systems, during June and July 2019. Articles, theses, and dissertations were analyzed in Portuguese, English, and Spanish, with no time frame definition. Results: Of the 6.847 productions, 10 were included, and the concept of social identity was described in 4 of them. Critical, prior, and consequential attributes for the social identity of transgender persons were identified, and the analysis of the concept substantiated the proposal of the diagnosis: Willingness to improve the social identity of the transgender person. Conclusion: Social identity establishes a relationship with health, and the proposed nursing diagnosis strengthens the sense of belonging of transgender people, enhancing their rights as citizens.

FACING UP COVID-19: WHAT CANNOT BE RELATIVIZED IN NURSING HIGHER EDUCATION

ABSTRACT Objective: to present reflective arguments on the measures to accelerate the training of nurses and their early insertion in the health system during the COVID-19 pandemic. Method: an analytical and theoretical-reflective text, based on the central construct of “Nursing knowledge”, whose theoretical framework of reference was formed by two of the fundamental patterns of knowing, from Chinn & Kramer's perspective: the ethical and the empirical. Results: newly graduated nurses, in the process of accelerated training, will have few resources available from the empirical knowledge pattern, both due to the reduced framework of knowledge evidence and to the difficulty in dealing with mechanisms that are often unknown. As they do not have levels of clinical knowledge, such as that developed in the applications of practical experience, recent graduates may have to confront situations that will impact on the ethical knowledge pattern. Conclusion: the acceleration in the training of Nursing students and their insertion in the health system in the current pandemic situation must be viewed with caution, as the risks are high, both from the point of view of clinical decision-making and from the perspective of facing dilemmas and ethical problems.

Validation of the “Interactive Breastfeeding Scale”: theoretical and empirical analysis

ABSTRACT Objective: To conduct a theoretical and empirical analysis of the Interactive Breastfeeding Scale. Method: A methodological study that followed the measurement method by Pasquali and was carried out in two stages: theoretical analysis with 40 nurses as content's judges and a pilot survey with 68 mothers of a maternity hospital of a university hospital in southeastern Brazil. Results: The evaluation with judges showed that the items of the scale are accurate on the theoretical concept, semantic adequation, and pertinence. From 58 items on the scale, 33 had a Content Validity Index greater than or equal to 0.80. The pilot survey allowed us to evaluate the items in the social and cultural context of the target population. In the end, the scale remained with 30 items. Conclusion and implication for the practice: The validation with the judges showed that the items of the Interactive Breastfeeding Scale are accurate to the theoretical concept regarding semantics and relevance and proved to be a reliable and valid instrument to evaluate the factors that interfere in mother-child interaction during breastfeeding.

Evidence of nursing patterns of knowing communicated by the brazilian press before Florence Nightingale’s model

ABSTRACT Objective: to identify evidence of nursing patterns of knowing disseminated by the Brazilian press before the implementation of Florence Nightingale’s model in Brazil and categorize topics of journalistic articles according to Carper’s and White’s patterns of knowing. Methods: categorical content analysis of materials related to Florence Nightingale, published in Brazil between 1850 and 1919, collected at Hemeroteca Digital. Four analysts identified themes of journalistic article, performing classification in patterns of knowing. Results: there was a predominance of evidence of the sociopolitical pattern followed by the empirical pattern. In the analyses per decade, ethical and aesthetic patterns showed predominance between 1860 and 1870, respectively. Conclusion: White’s classification by nursing patterns of knowing was useful in understanding precursor themes of professional/disciplinary knowledge that spread in Brazil, linked to Nightingale’s character, in addition to the repercussions of her actions and her expanded sociopolitical perspective.

T-NDX Diagram: Educational Technology Used to Teach Diagnostic Reasoning Based on Nursing Theories

PURPOSE

To describe an educational technology to be applied to the teaching and learning of diagnostic judgment based on nursing theories.

METHODS

A methodological study with 10 stages for the development of educational technology.

FINDINGS

An innovative educational technology is proposed to incorporate theoretical and methodological domains in a V-shaped diagram for the diagnosis judgment.

CONCLUSIONS

The technology is innovative in integrating theory and method in a more comprehensive and original way, considering the philosophies and world views of students throughout the reasoning process.

IMPLICATIONS FOR NURSING PRACTICE

T-NDx Diagram may be useful in enhancing the integration of philosophical and theoretical knowledge and diagnostic judgment, especially for nursing undergraduate students.

Nursing theories in the conceptual expansion of good practices in nursing

OBJECTIVE

To discuss the contribution of nursing theories in the conceptual expansion of good practices in the area for the construction of the unified health system (Sistema Único de Saúde - SUS).

METHOD

Theoretical production of reflection, based on the neomodern framework of philosophy of science.

RESULTS

The knowledge and political, social and epistemological commitments of nursing are discussed, highlighting the relationship of the theories with good practices for the construction and application of knowledge in the area in the context of the Brazilian health care system. Reflection on how middle-range theories can help in solving dichotomies between discipline, theory, practice, producers and consumers of knowledge is made.

CONCLUSION

Original reflections on the contributions of disciplinary and professional knowledge of nursing theories to the creation of SUS are presented, defending a creation through the academy-service partnership, in which the theories start being incorporated into a new concept of nursing practices aligned to neomodern principles of science.

Subconjunto terminológico da classificação internacional para a prática de enfermagem (CIPE®) para assistência à amamentação: estudo de validação de conteúdo

Resumo Objetivo: Realizar a validação de conteúdo dos enunciados de diagnósticos, resultados e intervenções de enfermagem contidos no subconjunto terminológico da Classificação Internacional para a Prática de Enfermagem (CIPE®) para assistência à mulher, à criança e à família em processo de amamentação. Métodos: Estudo de validação de conteúdo com 74 juízes que avaliaram 98 diagnósticos/resultados de enfermageme de 396 intervenções relacionadas aos diagnósticos/resultados validados. Resultados: Treze diagnósticos/resultados obtiveram IVC ≥ 0,8 (13,3%); 34 de 0,6 a 0,79 (34,7%) e; 51 menores que 0,6 (52%). Após a validação, para os diagnósticos “Falta de privacidade”, “Tomada de decisão pela amamentação, eficaz”, “Desempenho de papel de mãe, eficaz” e “Desempenho de papel de mãe, melhorado” foi necessário o estabelecimento de três enunciados de resultados de enfermagem. Na segunda etapa, 350 intervenções de enfermagem, obtiveram IVC ≥ 0,80. Conclusão: Foram validados 50 diagnósticos/resultados e 350 intervenções de enfermagem.

Elaboration and validation of an ICNP® terminology subset for patients with acute myocardial infarction

ABSTRACT Objective: To elaborate a terminological subset for the International Classification for Nursing Practice (ICNP®) for patients with acute myocardial infarction using the Activities of Living Model. Method: A methodological study which followed the guidelines of the International Nursing Council and was based on theoretical framework of the Activities of Living Model for its elaboration. Content validation was performed by 22 nursing specialists. Results: Twenty-two (22) diagnoses and 22 nursing outcomes were elaborated. Of these, 17 nursing diagnosis statements and 17 nursing outcome statements presented Content Validity Index (CVI) ≥ 0.80. Of the 113 elaborated nursing interventions, 42 reached a CVI ≥ 0.80, and 51 interventions made up the terminological subset after the expert suggestions. Conclusion: The ICNP® was suitable for use with the Activities of Living Model, having compatible terms with those used in clinical nursing practice, and valid for construction of the terminological subset for patients with acute myocardial infarction and most likely to facilitate clinical nursing judgment.