Brazilian Validation of the Nursing Outcomesfor Acute Painijnk_1230 54..58

Amália de Fátima Lucena, RN, PhD, Ilesca Holsbach, RN, Lisiane Pruinelli, RN, MSN,Adriana Serdotte Freitas Cardoso, RN, MSN, and Bruna Schroeder Mello, RN

Amália de Fátima Lucena, RN, PhD, is an Adjunct Professor at Nursing School, Federal University of Rio Grande do Sul,RGS, Brazil, Ilesca Holsbach, RN, is a Registered Nurse and Bruna Schroeder Mello, RN, is a Registered Nurse at HospitalIrmandade Santa Casa, Porto Alegre, RGS, Brazil, Lisiane Pruinelli, RN, MSN, is a Registered Nurse andAdriana Serdotte Freitas Cardoso, RN, MSN, is a Registered Nurse at Hospital de Clínicas of Porto Alegre, FederalUniversity of Rio Grande do Sul, RGS, Brazil.

Search terms:Content validation study, nursingdiagnosis, nursing outcome

Author contact:lisipru@hotmail.com, with a copyto the Editor: journal@nanda.org

PURPOSE: Validate the outcomes from the Nursing Outcomes Classification(NOC) for the Acute Pain nursing diagnosis.METHODS: The content validation of the seven NOC outcomes and their respec-tive indicators was performed using an adaptation of Fehring’s model and wasanalyzed by descriptive statistics.FINDINGS: Six were classified as critical and one was classified as supplemental.From the total of 118 indicators, 103 were validated. Of these, 27 were classified ascritical and 76 as supplemental.CONCLUSIONS: The use of the NOC is a viable alternative for the assessmentand identification of best practices in nursing care.CLINICAL RELEVANCE: Validation studies of nursing classifications corrobo-rate the use of the component elements of these instruments in a variety of caresettings.

The nursing process is a method for organizing nursingcare. Among its main purposes are the identification andinterpretation of human responses by means of a nursingdiagnosis (ND), followed by planning and implementationof actions, the effectiveness of which is then evaluated bythe outcomes obtained (Almeida, Lucena, Franzen, &Laurent, 2011).

Advances in knowledge and use of the nursing processhave driven the construction of standardized terminologiesfor the elements of nursing practice (diagnosis, inter-vention, and outcomes) to enable the classification andorganization of these elements into coherent units of cross-referenced information. These classification systemsfacilitate the communication and encoding of informationfor entry into computer databases and provide other majorbenefits to clinical practice, teaching, and research innursing (Almeida et al., 2011). An integrative review (Furuya,Nakamura, Gastaldi, & Rossi, 2011) of nursing classificationsystems showed that the most widely used such systemsare the NANDA-I (2008), the Nursing Interventions Classi-fication (NIC; Bulechek, Butcher, & Dochterman, 2008), andthe Nursing Outcomes Classification (NOC; Moorhead,Johnson, Maas, & Swanson, 2008).

Use of these taxonomies of nursing terminology hasbecome increasingly commonplace, with a view to creatinga uniform, standard language for the classification of diag-nostic assessment, interventions, and expected outcomes

by means of an evidence-based nursing approach (Müller-Staub et al., 2008). However, if, on the one hand, extensiveresearch on NDs have used the standardized language ofNANDA-I, the NIC and the NOC—particularly the latter—remain relatively unexplored in research (Scherb et al.,2011). An analysis of NOC-related studies showed that mosthave been conducted in the United States, and less thanhalf have focused on the applicability of the NOC in clinicalpractice (Furuya et al., 2011). This is indicative of a gap inknowledge of the NOC and a need to identify outcomesassociated with NDs and interventions, so as to expand theimplementation of standardized taxonomies in a clinicalpractice setting (Azzolin, 2011).

The NOC (Moorhead et al., 2008) is a standardized clas-sification of nursing outcomes that can be used in the plan-ning and outcome evaluation stages of the nursing process.It is structured into 7 domains, 31 classes, and 385 out-comes. One of its chapters links NOC outcomes andNANDA-I NDs. In this chapter, outcomes are presented intwo tiers according to their connection with NDs: “Critical”outcomes, considered significantly important in the assess-ment of a given ND, and “Supplemental” outcomes, whichare moderately important but often used in the assessmentof the corresponding ND.

For each outcome, there is a definition, a list of indica-tors, and a five-point Likert-type scale for patient evalua-tion. Scales are anchored so that one (1) expresses the

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54 © 2012, The AuthorsInternational Journal of Nursing Knowledge © 2012, NANDA International

International Journal of Nursing Knowledge Volume 24, No. 1, February 2013

worst score, and five (5), the most desirable score. As notedearlier, although it provides important indicators for theevaluation of nursing outcomes, this classification is stilllittle explored in the clinical setting.

Some Brazilian healthcare facilities use the nursingprocess and the NANDA-I, NIC, and NOC classifications inclinical practice, teaching, and research. One of these facili-ties is a large university hospital in Southern Brazil, wherethe present study was carried out. At this hospital, thenursing process is based on the Basic Human Needs theo-retical model (Horta, 1979) and is fully electronic across allfive stages: data collection, ND, nursing care plan andnursing prescriptions, implementation of nursing interven-tions, and evaluation (Almeida et al., 2011). NDs follow theNANDA-I terminology (2008) and nursing care planningmostly follows the NIC (Bulechek et al., 2008). The laststage of the nursing process (outcome evaluation),however, consists of a simple observation of the progres-sion and outcome of the ND, using the terms stable,improved, worsened, and resolved, and is thus not backedby any standardized classification system such as the NOC.However, the use of more specific instruments for the mea-surement of outcomes in patients who receive one or moreNDs and interventions may contribute to the identificationof best practices.

Thus, although the nursing process followed at this facil-ity constitutes a model for other Brazilian university hospi-tals, there is still room for improvement; one of its currentgoals is to establish NOC-based measurement of nursingoutcomes. Toward this end, validation studies of classifica-tion systems have emerged as important methodologicaltools to support the implementation of these systems in apractice setting (Azzolin, 2011; Head et al., 2004; Schneider,Barkauskas, & Keenan, 2008; Seganfredo & Almeida, 2010).

Following this line of reasoning, the aim of the presentstudy was to conduct content validation of NOC outcomesand indicators for Acute Pain, one of the NDs most com-monly established in hospital nursing practice (Ferreira,Predebon, Cruz, & Rabelo, 2011; Lucena & Barros, 2006;Lucena, Guterréz, Echer, & Barros, 2010). Furthermore, painassessment is a major object of nursing investigations,which supports the idea of exploring its context in a hospitalsetting (Arbour & Gélinas, 2011; Haslam, Dale, Knechtel, &Rose, 2011). According to the NANDA-I (2011), pain is “anunpleasant sensory and emotional experience associatedwith actual or potential tissue damage, or described interms of such damage.” Acute pain may be of sudden orslow onset, of any intensity from mild to severe, with ananticipated or predictable end and duration of less than6 months.

Thus, in view of the need for more in-depth knowledge ofthe NOC as a tool for the assessment of nursing care inclinical practice, the aim of this study was to validate thecontent of NOC outcomes and indicators, selected by theNOC–NANDA-I linkages (Moorhead et al., 2008), for the NDof Acute Pain in patients admitted to medical, surgical, andintensive care units.

Methods

This was a content validation study, based on the frame-work proposed by Fehring (1987) and conducted at a largeuniversity hospital in Southern Brazil. Consensus-validationstudies are low cost, easy to conduct, and tap into expertnurses’ knowledge of diagnoses, interventions, and out-comes in clinical practice to confirm the importance andapplication of these elements in different settings ofnursing care (Azzolin, 2011; Lunney, Mcguire, Endozo, &Mclutsh-Waddy, 2010).

The sample comprised 14 expert staff nurses of themedical, surgical, and intensive care units of the hospitalwhere the study was conducted.

The criteria for the inclusion of expert nurses werebased on those advocated by Fehring (1987) and adapted bySeganfredo and Almeida (2010): (a) have at least 2 years ofprofessional experience, including at least 1 year of experi-ence at the study facility, using the nursing process; (b) takepart or have taken part in nursing process-related studyand training activities at the facility for at least 6 months,over the past 5 years, or have published academic and/orscientific research on the nursing process and nursing clas-sifications; and (c) have at least 1 year of experience withdirect patient care in the nurse’s area of clinical expertise(medical, surgical, or critical care nursing).

Data were collected by means of a two-part instrument.The first part was designed to validate three “critical” out-comes and four “supplemental” outcomes among the 23listed for the ND of Acute Pain in the NOC–NANDA-I link-ages (Moorhead et al., 2008). The instrument consisted ofa six-column table: column 1 presented the proposedoutcome and its definition, and columns 2–6 contained afive-point Likert-type scale on which the expert nursescored the relevance of each outcome to the ND of AcutePain (1, not relevant; 2, little relevant; 3, relevant; 4, veryrelevant; 5, extremely relevant). Finally, there was a blankfield where experts could leave notes, suggestions, andcriticism.

The second part of the instrument was designed to vali-date the 118 indicators associated with previously validatedoutcomes. It also consisted of a six-column table, withcolumn 1 presenting the proposed NOC indicators for eachSuggested or Optional outcome associated with the ND ofAcute Pain (Moorhead et al., 2008), and columns 2–6 con-taining the same five-point Likert-type scale used in partone of the instrument, on which the expert nurse scored theimportance of each indicator to the ND of Acute Pain.Again, there was a blank field where experts could leavenotes, suggestions, and criticism.

Data were analyzed by means of descriptive statistics.Weighted ratios were calculated for the scores assigned toeach outcome and indicator as follows: 1 = 0; 2 = 0.25; 3 =0.50; 4 = 0.75; 5 = 1.00 (Fehring, 1987). Weighted ratios foreach indicator were averaged to produce ratios for impor-tance. Outcomes and indicators with weighted ratios �0.8were considered major or critical, those with weighted

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ratios <0.8 and �0.5 were considered supplemental, andthose with ratios <0.5 were excluded.

Results

All seven outcomes presented for expert assessmentwere validated for the ND of Acute Pain. Six of the sevenhad a weighted average score of >0.80 and were thus vali-dated as critical; one had a weighted average score of 0.75and was validated as supplemental (Table 1).

The Pain Level outcome is defined as the “severity ofobserved or reported pain” and has 14 indicators (Moorheadet al., 2008). Five of these were validated as critical, sevenwere validated as supplemental, and two were excluded.

The Vital Signs outcome is defined as the “extent towhich temperature, pulse, respiration, and blood pressureare within normal range” (Moorhead et al., 2008). Thisoutcome has eight indicators, of which four were validatedas critical and four as supplemental.

The Pain Control outcome is defined as “personal actions tocontrol pain” and has 11 indicators for measurement (Moor-head et al., 2008). Of these, five were validated as critical,five were validated as supplemental, and one was excluded.

The Comfort Level outcome is defined as the “extent ofpositive perception of physical and psychological ease”(Moorhead et al., 2008). It consists of nine indicators,all of which were validated: four as critical and five assupplemental.

The Symptom Control outcome is defined as “personalactions to minimize perceived adverse changes in physicaland emotional functioning” (Moorhead et al., 2008). It has 11indicators for measurement, of which 3 were validated ascritical and 8 as supplemental.

The Anxiety Level outcome is defined as the “severity ofmanifested apprehension, tension, or uneasiness arisingfrom an unidentifiable source” (Moorhead et al., 2008). Ithas 31 indicators, of which 1 was validated as critical, 21 werevalidated as supplemental, and 9 were excluded.

The Stress Level outcome is defined as the “severity ofmanifested physical or mental tension resulting fromfactors that alter an existing equilibrium” (Moorhead et al.,2008). It has 34 indicators for measurement, of which 5were validated as critical, 27 were validated as supplemen-tal, and 2 were excluded.

Thus, of the 118 indicators included for content valida-tion, 27 were validated as critical, 77 were validated assupplemental, and 14 were excluded. The 27 indicators vali-dated as critical for the ND of Acute Pain, belonging to eachof the seven validated NOC outcomes, are shown in Table 2.

Discussion

The seven NOC outcomes selected for validation byexpert nurses had weighted ratios that classified six (Pain

Table 1. Nursing Outcomes Validated as Critical and Supplemental for the Nursing Diagnosis of Acute Pain, WithWeighted Ratios and NOC Linkages to NANDA-I

Outcome Weighted ratio Level of validation NANDA-I linkage

Pain Level 0.96 Critical SuggestedVital Signs 0.91 Critical OptionalPain Control 0.86 Critical SuggestedComfort Level 0.82 Critical SuggestedSymptom Level 0.82 Critical OptionalAnxiety Level 0.80 Critical OptionalStress Level 0.75 Supplemental Suggested

Table 2. Indicators of the Nursing Outcomes Validatesas Critical for the Nursing Diagnosis of AcutePain, With Weighted Ratios

Outcome Critical indicatorsWeightedratio

Pain Level Reported pain 0.96Length of pain episodes 0.91Facial expressions of pain 0.91Moaning and crying 0.84Blood pressure 0.84

Vital Signs Systolic blood pressure 0.93Diastolic blood pressure 0.91Respiratory rate 0.89Radial pulse rate 0.82

PainControl

Uses analgesics appropriately 0.98Uses nonanalgesic relief measures 0.87Reports changes in pain symptoms or

sites to healthcare professional0.82

Recognizes symptoms of pain 0.80Reports pain controlled 0.80

ComfortLevel

Physical well-being 0.91Pain control 0.91Symptom control 0.84Psychological well-being 0.89

SymptomLevel

Recognizes symptom onset 0.87Recognizes symptom persistence 0.82Recognizes symptom severity 0.82

AnxietyLevel

Agitation 0.86

StressLevel

Blood pressure increased 0.87Radial pulse rate increased 0.82Respiratory rate increased 0.82Agitation 0.82Use of psychotropic drugs increased 0.80

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Level, Vital Signs, Pain Control, Comfort Level, SymptomLevel, and Anxiety Level) as critical and one (Stress Level)as supplemental for the ND of Acute Pain. This corroboratesthe importance of these outcomes in the nursing assess-ment of patients with a diagnosis of Acute Pain. The indica-tors of these outcomes can be used by nurses to scorepatient condition. The present study also determined whichof these indicators are considered by expert nurses to beessential to the assessment process (Moorhead et al.,2008).

The indicators validated as critical for the Pain Leveloutcome were reported pain, length of pain episodes,moaning and crying, and facial expressions of pain, whichcharacterize the verbalization and expression of pain bypatients and can thus be interpreted as behavioraldescriptors of the presence of pain. Indeed, these indica-tors have been described in other studies of pain, whichhave stressed the importance of subjective patient reportsand changes in patient expression and behavior whenexperiencing pain (Arbour & Gélinas, 2011; Haslam et al.,2011).

Validation of Pain Control indicators also showed theimportance of self-reporting of pain characteristics, of rec-ognition of pain symptoms, and of pain relief provided byanalgesic measures. It bears noting that pain is associatedwith a subjective experience and can thus be evaluatedmore accurately when a report can be elicited from theexperiencing individual. Furthermore, patient descriptionsof pain encompass issues related to personal emotional andbehavioral aspects and reflect sociocultural variables thatshould be taken into account by the healthcare provider.Some authors believe the verbalization of pain is the mostreliable indicator of its actual presence and should be con-sidered the gold standard for the evaluation of thissymptom (Arbour & Gélinas, 2011; Souza, Pereira, Cardoso,& Hortense, 2010).

The indicators of the Symptom Level, Pain Level, andPain Control outcomes, which were validated as being ofcritical relevance, reflect subjective, patient-reported infor-mation regarding recognition of the onset, persistence, andseverity of pain. Verbally expressed information on pain, aswell as reports of the measures used by the patient toachieve pain control, can be helpful not only in guiding theND but also in guiding nurses’ decisions to which interven-tions can and should be implemented more effectively(Souza et al., 2010).

Validation of critical indicators of the Comfort Leveloutcome provided clear evidence of the impact of physicaland psychological factors on the experience of acutepain. These factors influence assessment and, particularly,management and control of acute pain because interven-tions will change depending on the etiology of pain(Andrade, Barbosa, & Barichello, 2010; Souza et al., 2010).Regarding psychological well-being, a longitudinal studyshowed that the anxiety and depression preceding a sur-gical procedure worsened as episodes of acute pain wereexperienced. This demonstrates the significant implica-

tions of management of acute pain, in light of the multi-dimensional effects of this symptom and of the interfacebetween primary and secondary care (Carr, Thomas, &Wilson-Barnet, 2005).

Comparison of the Stress Level and Anxiety Level out-comes revealed similarities both in the definitions of theseoutcomes and in the sets of indicators used for their mea-surement. However, unlike the Anxiety Level outcome, ofwhich only one indicator (agitation) was validated as criti-cal, the Stress Level outcome had four other indicatorsvalidated as being of critical relevance: blood pressureincreased, radial pulse rate increased, and respiratory rateincreased, as well as agitation. These signs and symptomsmay be associated with the neurovegetative changes thatare usually present in patients with acute pain and canoften be detected in their assessment (Andrade et al., 2010;Haslam et al., 2011).

Validation of the Anxiety Level outcome again deter-mined agitation to be a critical indicator, providing furtherevidence of the importance of behavioral parameters, notonly physiological variables (Haslam et al., 2011).

On the other hand, systolic and diastolic blood pres-sure, respiratory rate, and radial pulse rate were validatedas indicators for the Vital Signs outcome, which corrobo-rates the importance of using these parameters and mea-suring their variations, which may be associated withacute pain. Reviews of the nursing records of patientsexperiencing pain reinforce this premise, as they haveidentified frequent descriptions of changes in physiologi-cal parameters, once again demonstrating the importanceof measuring these vital signs (Arbour & Gélinas, 2011;Haslam et al., 2011).

The data reported herein show that the NOC is a validtool for clinical practice and provides a valuable aid for theassessment of patients with an ND of Acute Pain. The rel-evance of this finding lies in the fact that the NOC contrib-utes to the qualification of a variety of areas of nursing inwhich pain assessment practices are still suboptimal. Inseveral studies, nurses have reported failure to useadequate pain assessment practices, which suggests thatpain is not evaluated consistently. This further implies thatnonrelief of acute pain remains prevalent and that analge-sia often remains inadequate despite advances in pain man-agement (Bucknall, Manias, & Botti, 2001; Calil & Pimenta,2005; Kerr et al., 2004).

Therefore, the use of nursing classifications, such as theNOC, can aid in the qualification of nursing practices andthe documentation of their results. Studies on the NANDA-I/NIC/NOC linkages provide input for the improvement ofpatient care practices by showing that, in addition to diag-nosis, care requires intervention and evaluation of indi-vidual health needs (Azzolin, 2011). Hence, nurses must notonly establish accurate NDs but also determine appropriateoutcomes and interventions that will enable the achieve-ment of a clinical practice that provides the conditionsrequired by patients and their families (Head et al., 2004;Kautz, Kuiper, Pesut, & Williams, 2006; Müller-Staub, 2009).

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Conclusions

This study validated the content of seven NOC outcomeslinked to the ND of Acute Pain, six considered critical andone considered supplemental according to the methodemployed for classification. Of the 118 corresponding indi-cators, 104 were validated. Of these, 27 were consideredcritical, 77 were considered supplemental, and 14 wereexcluded.

The main outcomes and indicators for the assessment ofacute pain included physiological and behavioral compo-nents, which interact among themselves, with the patient,and with the environment, as pain is a phenomenon thattranscends biophysiological aspects. We conclude that theuse of the NOC, although recent in Brazil, is a viable methodfor the assessment and identification of best practices innursing care, as all outcomes and a substantial number ofindicators were validated by our panel of expert nurses foruse in clinical practice.

At the study hospital, the transition to an electronicnursing process and the implementation of NANDA-I diag-noses and NIC interventions brought about significantimprovements in nursing records. However, implementa-tion of the NOC has yet to be achieved. Thus, the implica-tions of this study for nursing practice include thepossibility that its results will support the addition of theNOC to the hospital’s electronic records system, alongsideNANDA-I and the NIC.

One limitation of this study was the fact that all nursingexperts were recruited from the same facility, which made itimpossible to compare findings with the opinions of nursesfrom other centers.

As a suggestion for further research, we recommendthat additional studies be conducted with the objective ofvalidating these outcomes and indicators in a clinicalsetting, so as to enable a greater understanding of theirapplicability in clinical practice.

Acknowledgments. This project and research wasapproved and supported by the Research and Post-Graduation Group and Fundo de Incentivo à Pesquisa eEventos of Hospital de Clínicas of Porto Alegre, FederalUniversity of Rio Grande do Sul, Brazil.

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