Nursing diagnoses accuracy: from theory to practice

• Grant number: 09/08000-4
• Support Opportunities: Regular Research Grants
• Start date: July 01, 2009
• End date: June 30, 2011
• Field of knowledge: Health Sciences - Nursing - Medical-Surgical Nursing
• Principal Investigator: Diná de Almeida Lopes Monteiro da Cruz
• Grantee: Diná de Almeida Lopes Monteiro da Cruz
• Host Institution: Escola de Enfermagem (EE). Universidade de São Paulo (USP). São Paulo , SP, Brazil

Abstract

During the master program advocated in 2006, set ourselves to develop a scale to "measure" the accuracy of nursing diagnoses from the written data. The instrument developed was called Scale Accuracy of Nursing Diagnoses - NDAS, and analysis of records can indicate the ordinal values the degree of accuracy of the nursing diagnosis statement by the nurse who assessed the patient. Facing the importance of defining the accuracy of nursing diagnoses as a variable and stage of development of the NDAS, the objectives of this study are: 1) To test the NDAS in clinical practice: describe the degree of accuracy of the nursing diagnoses documented in clinical practice, identifying factors involved in the establishment of diagnostic accuracy evaluated by NDAS with zero or moderate; test the intra examiner agreement, and test the interrater reliability. 2) To examine possible associations between selected variables and accuracy: to test the association of time with the diagnostic accuracy of trained, titration, duration of clinical experience in the area, familiarity with the classification of nursing diagnoses, the diagnostic studies on content, content on reasoning in clinical studies, use of time of diagnosis in clinical practice, self-assessment of ability to make accurate diagnoses, category of diagnosis, time on the implementation of the classification in the institution, the complexity of the patient (degree of dependence), type of disease that led to hospitalization (acute or chronic) and age of the patient. The study consists of a desk research, cross-sectional descriptive in nature, with qualitative and quantitative analysis of the data. The data will be analyzed in the research will be collected from medical records of patients hospitalized in general medical and surgical clinic of the University Hospital of the University of São Paulo (HU-USP), which is the national reference in the use of the nursing diagnosis in clinical practice. The number of records necessary for the development of the study will be defined as data are collected, because no similar studies in which base any estimate. The charts that will be part of the study follow the following criteria: belonging to patients over 18 years old of both sexes, and belong to the patients admitted between July 2005 and June 2008. The exclusion criteria of the chart are: lack of documentation of the nursing admission assessment, lack of documentation of the nursing diagnoses arising from the admission assessment and registration of admission made by nurses who can not provide personal information for characterization (not agree participate in the study, no more working in the institution or are away from activities for any reason). The data collection will be held on 03 stages: 1) Consultation of nurses in the exercise unit of Clinical Medicine and Surgery on the interest to participate. 2) Selection of records with records of admission made by nurses who take part in the study. 3) Transcript of records and analysis of nursing (nursing diagnoses and admission) in the form needed to apply NDAS. The multiple transcripts of five (fifth, tenth, fifteenth, etc.)will be implementation by a second researcher (guiding the study) to estimate the reliability between raters. The multiple transcripts of six (the sixth, twelfth, eighteenth, etc.) will be reapplied by the researcher principal fifteen days after the first application to estimate the reliability of intra-evaluator. NDAS to test in clinical practice the data will be analyzed according to each specific objective proposed. (AU)