Nursing Outcomes for Brazilian Pediatric Patients Hospitalized With Deficient Diversional Activity

Nursing Outcomes for Brazilian PediatricPatients Hospitalized With DeficientDiversional ActivityMiriam de Abreu Almeida RN PhD Marcos Barragan da Silva RN Bruna Paulsen PanatoAna Paula de Oliveira Siqueira RN and Maria do Carmo Rocha Laurent RN

Miriam de Abreu Almeida RN PhD is an Associate Professor in the Postgraduate Program of the School of Nursing at theFederal University of Rio Grande do Sul Porto Alegre Rio Grande do Sul Brazil and Coordinator of the Nursing ProcessCommission at the Hospital de Cliacutenicas de Porto Alegre Porto Alegre Rio Grande do Sul Brazil Marcos Barragan da SilvaRN is a Doctoral Student in the Postgraduate Program of the School of Nursing at the Federal University of Rio Grande doSul Porto Alegre Rio Grande do Sul Brazil and an Assistant Nurse at Hospital Santa Casa de Uruguaiana Rio Grande doSul Brazil Bruna Paulsen Panato is a Nursing Graduate Student at the School of Nursing Federal University of Rio Grandedo Sul Porto Alegre Rio Grande do Sul Brazil Ana Paula de Oliveira Siqueira RN is a Masterrsquos Student in thePostgraduate Program of the School of Nursing Federal University of Rio Grande do Sul Porto Alegre Rio Grande do SulBrazil and an Assistant Nurse at Hospital de Pronto Socorro de Canoas Rio Grande do Sul Brazil and Maria do CarmoRocha Laurent RN is an Assistant Nurse at the Hospital de Cliacutenicas de Porto Alegre Porto Alegre Rio Grande do SulBrazil

Search termsChild hospitalized classificationnursing diagnosis outcomeassessment pediatric nursingvalidation study

Descritores de assuntoAvaliaccedilatildeo de Resultados (cuidadosde sauacutede) Classificaccedilatildeo CrianccedilaHospitalizada Diagnoacutestico deEnfermagem Enfermagempediaacutetrica Estudos de validaccedilatildeo

Author contactmiriamabreu2gmailcom with acopy to the Editorjournalnandaorg

Suporte financeiro Fundo dePesquisa e Evento do Hospital deCliacutenicas de Porto Alegre RS Brasil

Financial support This studyreceived financial support from theFund of Research from Hospital deClinicas de Porto Alegre

PURPOSE To validate the content of nursing outcomes for pediatric patientshospitalized with a nursing diagnosis of deficient diversional activityMETHODS The nursing outcomes were evaluated by expert nurses from a Bra-zilian hospital the nurses used a Likert-type scale We considered those that hada weighted average of 080 as valid outcomesFINDINGS Eight (5714) nursing outcomes and 54 (4538) indicators werevalidatedCONCLUSIONS The study suggests that nursing outcomes validated by theexperts are pertinent for Brazilian pediatric patients hospitalized and diagnosedwith deficient diversional activityIMPLICATIONS FOR PRACTICE Nursing Outcomes Classification is a viablealternative for the assessment of nursing care outcomes Further studies shouldinvestigate the applicability of these data in clinical practiceOBJETIVOS Validar o conteuacutedo (Modelo de Fehring adaptado) dos Resultadosde Enfermagem NOC para pacientes pediaacutetricos hospitalizados com o diagnoacutesticode enfermagem Atividade de Recreaccedilatildeo DeficienteMEacuteTODOS Os Resultados de Enfermagem foram avaliados por sete enfermeirosexperts de um hospital brasileiro utilizando-se uma escala Likert validando-seaqueles que atingiram o escore de 080RESULTADOS Oito (5714) Resultados de Enfermagem e 54 (4538) indica-dores foram validadosCONCLUSOtildeES Os Resultados de Enfermagem validados foram consideradosimportantes pelos experts para pacientes pediaacutetricos brasileiros hospitalizadoscom este diagnoacutesticoIMPLICACcedilOtildeES PARA A PRAacuteTICA A NOC consiste em alternativa para avaliaros resultados dos cuidados de enfermagem Em continuidade ao estudo seraacuteinvestigada a aplicabilidade destes dados na praacutetica cliacutenica

One of the challenges faced by pediatric nurses is to tryto make the experience of hospitalization less unsettling forthe child or adolescent (Haiat Bar-Mor amp Shochat 2003)Recreational activities are one of the strategies that help

children cope with hospital experience (Lima AzevedoNascimento amp Rocha 2009) These activities allow forplayful experiences and they are a form of expressing onersquosthoughts and emotions they allow for interaction commu-

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85copy 2013 The AuthorsInternational Journal of Nursing Knowledge copy 2013 NANDA InternationalInternational Journal of Nursing Knowledge Volume 24 No 2 June 2013

nication and building a cultural understanding (Branco2005) These activities may help build and promote a betterunderstanding of child development (Queiroz Maciel ampBranco 2006)

It is well known that the experience of staying in thehospital often makes children stop participating in recre-ational activities Studies show that the hospital environ-ment is in itself stressful which may also have apsychological impact on the child (Carvalho amp Begnes 2006Jansen Santos amp Favero 2010)

In this sense nurses use the NANDA-I nursing diagnosisfor deficient diversional activity (DDA) (00097) The diag-nosis is defined as ldquo[d]ecreased stimulation from (or inter-est or engagement in) recreational or leisure activitiesrdquo Ithas two defining characteristics patientsrsquo statementsregarding boredom (eg I wish there was something to doto read) usual hobbies cannot be undertaken in the hospitalenvironment and the related environmental factor of lackof diversional activity (Herdman 2009) Using the nursingdiagnosis to evaluate the situation of hospitalized childrenthe nurse is able to carry out interventions aimed at obtain-ing more positive outcomes

Literature on nursing contains a growing number of ref-erences about recreation of hospitalized children A reviewfound that most studies focus on the effects of playing onchildren but recreation is still a recent practice and it isnecessary to strengthen it as an intervention valued likeany other scientific knowledge since it is considered essen-tial to child development and well-being (Leite amp Shimo2007 Maia Ribeiro amp Borba 2011)

In this context Brazilian nurses are striving to identifyoutcomes that are sensitive to nursing practices TheNursing Outcomes Classification (NOC) is being widely usedin this context to describe the health status behavior orperception of an individual family or community measuredon a continuum and as a response to one or more nursinginterventions (Moorhead Johnson Maas amp Swanson2010) In pediatrics there is a noteworthy Brazilian studythat investigated the nursing outcomes and NOC indicatorswith or without the presence of ineffective breathingpattern diagnosis in children with congenital cardiopathies(Beltratildeo Silva Araujo amp Lopes 2011) A pilot study investi-gated the nursing outcomes of dehydrated children fromhospital admission to release The study showed significantchanges in seven out of eight outcomes (Scherb Stevens ampBusman 2007)

The assessment of nursing interventions is essential forthe improvement of healthcare quality NOC is useful forthe evaluation of the impact of nursing care The classifica-tion also helps rationalize nursing practices and achievegreater benefits from them (Seganfredo amp Almeida 2010)Studies that evaluate the results of nursing practice areessential to implement this classification in clinical practiceIn this case the validation of the nursing results content isrecommended to confirm whether the indicators representthe results of nursing interventions for a diagnosis ofnursing (Seganfredo amp Almeida 2011)

In southern Brazil the research project ldquoValidaccedilatildeo deResultados de Enfermagem segundo a Nursing OutcomesClassificationmdashNOC na praacutetica cliacutenica de um hospital univer-sitaacuteriordquo (Validation of Nursing Outcomes using the NursingOutcomes ClassificationmdashNOC in clinical practice at a uni-versity hospital) is being carried out to validate selectednursing outcomes using the NOCndashNANDA-I relationship forthe most frequent nursing diagnosis in patients under dif-ferent types of nursing care (Almeida et al 2008) Thediagnosis of DDA was one of the most frequent in pediat-rics the nursing outcomes for this diagnostic are still underinvestigation Working with a classification that measuresoutcomes is important as it permits the identification ofimpact quality efficacy and cost of nursing interventionsin patient care

Purpose

The goal of this study is to validate the NOC for hospi-talized children with a nursing diagnosis of DDA

Methods

We carried out a study aiming to validate content Weperformed the study using an adapted version of theFehring (1987) model since there are no specific criteria tosupport the validation of nursing outcomes (Melo et al2011) This adaptation refers to the validation of NOC indi-cators instead of characteristics that define a nursing diag-nosis and the criteria used to include the experts for thisvalidation The outcome content validation adapted fromthe model of diagnosis content validation proposed byFehring has been used in various studies (Head et al 2004Head Maas amp Johnson 2003)

The study was carried out in a university hospital insouthern Brazil Since 2000 the hospital has applied a com-puterized nursing process for medical history and physicalexamination nursing diagnosis healthcare prescriptionand evolutionevaluation The system used at the hospitalwas structured based on the theory of basic human needsput forth by Wanda Horta (1979) It takes into considerationthe NANDA-I Nursing Dx Nursing Interventions Classifica-tion (NIC) nursing care and the clinical practice of nursesThe evaluation of patients does not follow a standardizedterminology such as the NOC

The study included registered nurses (RNs) from thepediatric nursing services The service employs 57 RNs infour units clinical and surgical admission hematologyoncology and intensive care These services care for pedi-atric patients aged 30 days to 14 years and up to the age of18 years in some specific situations and have 109 bedsavailable

The pediatric units in this study are characterized byconcentrating their attention on the development of themethodology of care focusing on the child and the familyThe guiding premises are the ParentsChildren Joint Stay

Nursing Outcomes for Brazilian Pediatric Patients Hospitalized M A Almeida et al

86

System the Declaration of Rights of Hospitalized Childrenand Adolescents and humanization of the care of hospital-ized children and their family The pediatrics departmenthas two recreation rooms one of them specifically for pedi-atric oncology and the other for the other units There is apedagogical support program in which teachers connectedto the state public schools follow the schooling of hospital-ized pediatric patients in a playful individualized manneror in small groups with preappointed timetables usingvarious materials including computer science In additionthe nursing school promotes a project called ldquoGrowing withusrdquo in which students develop recreational activities withchildren and adolescents

The population sample included expert nurses who metthe following criteria minimum of 2 years of professionalexperience minimum of 1 year of employment at that hos-pital and using the nursing process minimum of 6 monthsof participation in the hospitalrsquos Committee of NursingProcess (COPE in Portuguese) andor publications in thefield of nursing process or NANDA-I NIC and NOC classifi-cations in the past 5 years

After the survey performed by query in the computer-ized system of the institution studied it was found that thediagnosis of DDA prevailed in the pediatric nursing serviceTherefore and based on the literature the nursing resultswere validated for this diagnosis

Data collection was carried out from July to September2011 The researchers sought nurses from Monday to Fridayduring their work hours in the morning afternoonand night shifts Nurses who agreed to participate in thestudy received the procedures for data collection Theywere given a deadline of at most 30 days to return theprocedures

The experimental procedures were divided into two partsThe first part contained information about the research anda questionnaire about the professional characteristics of theparticipants The second part contained the nursing out-comes selected for the study which were extracted from thechapter on NOCndashNANDA-I with a nursing diagnosis of DDA(Moorhead et al 2010) Three outcomes among the 17 pro-posed nursing outcomes considered suggested and addi-tional associated outcomes were excluded by theresearchers because they did not involve pediatric patientsFor the procedure 14 nursing outcomes were entered into atable with seven columns In the first column nursing out-comes with their definitions and respective indicators in thesecond to sixth columns 5-point Likert scales (1 = not rel-evant 2 = somewhat relevant 3 = relevant 4 = very relevant5 = extremely relevant) and the seventh column allowedspace for nursesrsquo suggestions criticism or observationsNext a Yes-No question was presented to ensure the impor-tance of the nursing outcomesndashnursing diagnosis relation-ship ldquoWould you use the Social Involvement outcome for theNursing Diagnosis Deficient Diversional Activityrdquo

Data were analyzed using descriptive statistics inMicrosoft Excel 2007 (Microsoft Corporation IncRedmond WA USA) The weighted average of the grades

attributed by the experts for each nursing outcome wascalculated based on the following values 1 = 0 2 = 025 3 =050 4 = 075 5 = 100 (Fehring 1987) The nursing out-comes and the indicators were considered validated for aweighted average of 080 In the present study nursingoutcomes were validated as major when the weightedaverage is 090 and minor when the weighted average isin the range of values between 080 and 089 All othernursing outcomes were discarded

The study was approved by the institutionrsquos HealthcareResearch Ethics Committee (Protocol 08184) all ethicalprocedures established by Resolution 19696 of the Brazil-ian National Healthcare Council were followed All partici-pants signed an informed consent form

Results

We will first present the characteristics of the populationsample of nurses Out of the 20 nurses who agreed toparticipate in the study nine returned the procedures andseven met the criteria for inclusion (experts)

The longest experience reported was 10 years (5714)RNs and those with masterrsquos degrees were reported amongthe population All experts had participated in the Commit-tee of Nursing Processes and three had publications in thefield of nursing process and classifications Table 1 shows thecharacteristics of the interviewees

Eight (5714) of the nursing outcomes for DDA werevalidated among the 14 included in the study Out of theeight three were major play participation child develop-ment middle childhood and child development 5 years(Table 2)

The nursing outcomes suggested for the NOCndashNANDA-Iconnection and the additional associated child develop-ment 2 years social interaction skills health promoting

Table 1 Characteristics of the Expert NursesmdashPortoAlegre 2011

Characteristics n = 7

Female 7 (100)Professional experience5ndash9 years 1 (1429)10ndash14 years 4 (5714)15 years 2 (2857)

SchoolingSpecialization 6(8572)Masterrsquos 1 (1428)

Participation in the committee6 monthsndash1 year and 6

months3 (4285)

1 and 7 monthsndash3 years 2 (2857)3 years or more 1 (1428)

Scientific publication about NP or classificationsYes 3 (4285)No 4 (5715)

NP nursing process

M A Almeida et al Nursing Outcomes for Brazilian Pediatric Patients Hospitalized

87

behavior loneliness severity and personal well-being hada weighted average of less than 080 and were thusdiscarded

The eight validated nursing outcomes had 119 indicatorsExperts validated 54 (4538) of them as shown inTable 3

The answer to the question about the relevance of spe-cific nursing outcomes for DDA was ldquoYesrdquo for all the vali-dated nursing outcomes

Discussion

Nursing outcomes are used in the planning and evalua-tion of the nursing process They allow for measurement ofpatient outcomes after nursing interventions The valida-tion of nursing outcomes is important for the definition ofthe level of nursing intervention for a specific outcome andindicator In the present pilot study we attempted to vali-date with expert nurses the nursing outcomes for hospi-talized Brazilian children with DDA

There is no consensus in the literature for the defini-tion of nurses with expertise in nursing outcomes (Meloet al 2011) However qualified professionals with experi-ence in pediatric nursing and application of the DDA diag-nosis were included they also had scientific productionrelated to nursing process and classifications All expertswere associated with the Committee of Nursing Processesof the institution (inclusion criterion) Since 2000the committee has been using the NANDA-I Nursing DxThe group includes nurses from a hospital that is academi-cally associated with a university in southern BrazilIt holds weekly meetings with nursing professorsresearchers in which members discuss create and refinethe nursing process for clinical practice they also carry

out clinical studies based on the NANDA-I NIC and NOCclassifications (Almeida Lucena Franzen Laurent amp Cols2011)

As with the nursing outcomes play participation had ascore of 096 with 500 of indicators validated play par-ticipation (096) expresses satisfaction with play activities(092) enjoys play activities (092) and uses social skillsduring play activities (089) The findings suggest thatexperts constantly evaluate whether children are partakingin recreational activities during hospital admission A studyaimed to investigate the applicability of therapeutic play ina protocol of venous puncture for hospitalized preschoolchildren The study showed positive results associated withtherapeutic play children become more cooperative andunderstood the need for the procedure (Martins RibeiroBorba amp Silva 2001) By participating in playful activitieschildren are able to have some sense of control over theevents (Carvalho amp Begnes 2006) this may facilitate theevaluation of the interventions carried out for nursing diag-nosis DDA using NOC

The fact that six indicators (600) of the nursing out-comes leisure participation were validated strengthens therelevance of leisure activities in nursing interventionsAuthors found that during surgical bandaging procedures9703 of pediatric patients investigated showed a reduc-tion in pain scores after the intervention It is an effectivestrategy for relief of pain and tension during the procedure(Kiche amp Almeida 2009)

Promoting playful activities during hospitalization mayfacilitate childrenrsquos everyday life Recreational activitiesfacilitate interaction and redirect the traditional model ofintervention thus improving the communication with thehealthcare team in pediatrics (Oliveira amp Oliveira 2008Queiroz et al 2006)

Table 2 DDA Validated Nursing OutcomesmdashPorto Alegre 2011

Nursing outcomes Connection NOCndashNANDA-I Scoref ()

Major(0116) Play participation Suggested 096(0108) Child development middle childhood Additional associated 092(0107) Child development 5 years Additional associated 092

Minor(0106) Child development 4 years Additional associated 089(0105) Child development 3 years Additional associated 085(0109) Child development adolescence Additional associated 085(1503) Social involvement Suggested 082(1604) Leisure participation Suggested 082

Discarded(0104) Child development 2 years Additional associated 078(1502) Social interaction skills Additional associated 078(1209) Motivation Suggested 060(1602) Health promoting behavior Additional associated 060(1203) Loneliness severity Additional associated 060(2002) Personal well-being Additional associated 057

Total validated 8 (5714)

DDA deficient diversional activity NOC Nursing Outcomes Classification


88

Table 3 Validated Indicators for Nursing Outcomes NOCmdashPorto Alegre 2011

Validated indicators Score n ()

Play participation (n = 8)(011601) Play participation 096(011610) Expresses satisfaction with play activities 092(011603) Enjoys play activities 092(011604) Uses social skills during play activities 089

4 (5000)Child development middle childhood (n = 15)(010802) Plays in groups 096(010809) Understands right and wrong 089(010812) Shows creativity 089(010808) Displays self-confidence 085(010807) Expresses feelings constructively 080

5 (3333)Child development 5 years (n = 17)(010716) Engages in creative play 096(010714) Follows simples rules of interactive games with peers 092(010717) Walks 089(010719) Runs 089(010706) Counts using finger 089(010703) Dresses self without assistance 085(010702) Skips 080(010704) Draws a person with head body arms and legs 080(010709) Uses complete sentence of five words 080

10 (5882)Child development 4 years (n = 15)(010616) Engages in creative play 096(010613) Distinguishes fantasy from reality 089(010611) Describes a recent experience 085(010601) Walks climbs runs 085(010612) Sings a song 080(010605) Throws overhand ball 080(010609) Uses sentences of four to five words short paragraphs 080

7 (4666)Child development 3 years (n = 16)(010513) Plays interactive games with peers 092(010507) Controls bowel in daytime 085(010508) Controls bladder in daytime 085(010512) Engages in magical thinkingfantasy 085(010514) Begins cooperative group play 085

5 (2941)Child development adolescence (n = 27)(010901) Practices good health habits 089(010904) Uses effective social interaction skills 089(010926) Observes rules 089(010920) Vents negative feelings in a non-destructive manner 089(010921) Respects others 089(010911) Uses effective coping strategies 089(010905) Uses conflict resolution skills 085(010912) Displays increasing levels of autonomy 085(010913) Describes personal value system 080(010923) Participates in extracurricular school activities 080(010927) Obeys laws 080(010910) Avoids alcohol use 080(010918) Avoids tobacco use 080(010919) Avoids recreational drug use 080

14 (5185)Social involvement (n = 11)(150311) Participates in leisure activities with others 096(150303) Interacts with family members 089(150301) Interacts with close friends 089(150313) Participates in team sports 085

4 (3666)Leisure participation (n = 10)(160413) Enjoys leisure activities 096(160412) Selects leisure activities of interest 092(160402) Expresses satisfaction with leisure activities 092(160403) Uses appropriate social interaction skills 089(160404) Feels relaxed from leisure activities 085(160407) Identifies recreational options 085

6 (6000)Total validated indicators for all NO 54 (4538)

NO nursing outcome NOC Nursing Outcomes Classification


89

Results suggest that specialists constantly assesswhether children are taking part in recreational activitiesduring hospitalization It is important for the professional tonot only assess whether the child plays but also whetherthe child expresses satisfaction regarding play and if thechild can develop social skills by living with other hospital-ized children Playing is part of the childrsquos treatment con-tributing to the quality of life during hospitalization andeasing negative impacts of the disease It is important toassess hospitalized childrenrsquos openness and involvement inplay (Azevecircdo 2011)

Five of the NOC related to child development were vali-dated child development middle childhood (092) childdevelopment 5 years (092) child development 4 years(089) child development 3 years (085) and child devel-opment adolescence (085) In total there are 90 indica-tors Out of the indicators 40 (4444) were validated(Table 3) The reason why so many indicators were vali-dated by the experts in the present study may be thevarious interventions used for different age groups

Recreational activities must take into account the devel-opment phases of the child considering the physical motorand cognitive capacities For a small child playing perme-ates their everyday life it is a way to learn physical mentaland emotional abilities Children often work through theirexperiences of illness and treatment by playing repeatingon the doll what is done to them Playing with dolls carsand construction sets and drawing coloring hearingstories and watching cartoons are activities appropriate tothis age group

While the child is in the hospital the nurse must assessthe childrsquos stage of development and preferences usingplay during care In this way recreational activities helpthe child understand diminish fear and sadness promotethe childrsquos adaptation to hospital and contribute to childdevelopment

Schoolchildren and adolescents usually verbalize moreabout the lack of recreational activities during their stay inthe hospital than the small children They often mentionboredom lack of something to do and they feel caught anddistant from their social group During their time in thehospital they appreciate games puzzles videogamesfilms and computer activities They are also motivated byactivities with their peers Girls like to do arts and craftssuch as making cards decorative boxes and costumejewelry

Changes in the childrsquos behavior and needs occur fastrequiring decisions that can only be made by professionalswho are trained to use interventions compatible with thechildrsquos development phase and that presents good resultsfor the child (Paula Ravelli Zinn amp Motta 2002) It is impor-tant to underscore the indicators of the outcomes moredirectly related to DDA plays in groups (096) engages increative play (096) follows simple rules of interactivegames with peers (092) engages in creative play (096)plays interactive games with peers (092) and begins coop-erative group play (085)

A study that evaluated planned recreation in the waitingrooms of pediatric units identified the fact that school-agechildren participate in recreational activities without muchneed for monitoring by the family On the other hand ado-lescents stay longer outside the waiting room and partici-pate less frequently in the recreational activities proposedThe study infers that the adolescents are more inhibitedbecause the pediatric unit is a physical environment that isdecorated specifically for children However it is believedthat children and adolescents even when undergoinghealth treatment are in a full process of biopsychosocialdevelopment and that it is important to plan and implementsystematic recreational activities in a hospital environment(Junior Coutinho amp Ferreira 2006)

When play activities provide situations of decisionmaking and autonomy they make the depersonalizing hos-pital environment more predictable and controllable Thesebehaviors favor dealing with the difficulties that arise fromhospitalization and also bring the hospital environmentcloser to the everyday reality of the pediatric patients(Motta amp Enumo 2004 Oliveira Gabarra Marcon Silva ampMacchiaverni 2009)

In Brazil the follow-up of child development is one of thebasic actions developed by the Ministry of Health regardingpediatric health care (Brasil Ministeacuterio da Sauacutede 2002) Ithas been underscored that children explore and interactwith their environment through play which makes it easierto identify the characteristics of child development(Valladares amp Silva 2011)

Fourteen indicators were validated in the study onnursing outcome child development adolescence The vali-dation of nursing outcomes is examined for what it meansregarding the diagnosis of DDA Studies state that childrenand adolescents are vulnerable to disease and hospitaliza-tion which are the early crises that they may face (AquinoLemos Silva amp Christoffel 2008) However the validatedindicators (Table 3) show that they bear little relation withthe Nursing Dx investigated even though nursing outcomesis considered by NOC as additional associated and wasapproved by 1000 of experts (Yes-No question)

This type of data needs to be evaluated in content vali-dation research in which the expert nurses have to thinkabout the importance of the content of nursing outcomesfor nursing diagnosis In the present study nurses may haveintuitively answered the experimental procedure and didnot carefully and critically think about the choice of nursingoutcomes for nursing diagnosis of DDA but rather for hos-pitalization

In relation to the nursing outcome social involvement weunderscore the indicators participates in leisure activitieswith others (096) and interacts with family members (089)Studies show that children playing and interacting with otherchildren are perceived as a sign of health and make mothersfeel less anxious about their children Moreover if parentsstay in the hospital and participate in the care of childrenthey enable new forms of patient care organization(Junqueira 2003 Strasburg Pintanel Gomes amp Mota 2011)


90

The nursing outcomes and their indicators are importanttools for the evaluation of pediatric patients hospitalizedwith DDA The importance of critical thinking in the choiceof outcomes that are sensitive to nursing is underscoredPediatric nurses develop practices that lessen the problemsof hospitalization However if nurses focus on the manage-ment and clinical aspects of care they may neglect theneeds of patients and favor the occurrence of DDA Studiesthat aim to focus on all the aspects of care should take thetype of diagnosis into consideration

Limitations of the Study

The limitations of the study include the 18 pages of pro-cedures which may be related to the low adherence ofparticipants within the established deadline (30 days) Butno other study about pediatric patients with DDA diagnosiswas found

Conclusions and Practical Implications

The present study aimed to validate the content ofnursing outcomes and their indicators for the diagnosis ofDDA in hospitalized children Eight (5714) of the 14nursing outcomes investigated were validated The nursingoutcomes had a total of 119 indicators 54 (4538) ofwhich were validated The nursing outcome play participa-tion had the highest score (096) Out of the indicatorsvalidated for all nursing outcomes the highest scores weregiven to play participation plays in groups engages in cre-ative play engages in creative play participates in leisureactivities with others and enjoys leisure activities (096) Allvalidated nursing outcomes were considered important bythe experts for hospitalized Brazilian children with DDAHowever several indicators are not directly related to rec-reational activities

Studies that validate nursing language are important todefine the knowledge of the profession It is becomingincreasingly important to apply the classifications ofnursing to improve the standards of clinical practice

The results of the present study suggest the need fordeveloping classifications that have psychosocial terminol-ogy aimed at children and adolescents This type of studyfavors the identification of outcomes sensitive to nursingpractices In other scenarios it is likely that othernursing outcomes would be considered important for thenursing diagnosis of DDA

Current practice requires that validation studies becarried out in real clinical settings The present pilot studycontributes to nursing outcomes and indicators with theevaluation of pediatric patients with DDA these evaluationscan be used in clinical practice and for further studies

Acknowledgment This study received financial supportfrom the Fund of Research from Hospital de Clinicas dePorto Alegre

References

Almeida M A Lucena A L Franzen E amp Laurent M C R (2011) Processode Enfermagem na Praacutetica CliacutenicamdashEstudos Cliacutenicos Realizados no Hospi-tal de Cliacutenicas de Porto Alegre [Nursing process in clinical practicemdashClinical studies carried out at the Hospital de Clinicas de Porto Alegre]Porto Alegre RS Artmed

Almeida M A Seganfredo D H Arauacutejo V G Lucena A F Unicovski M RBarreto L N M Frare F (2008) Validaccedilatildeo de Resultados de Enfer-magem segundo a Nursing Outcomes ClassificationmdashNOC na praacuteticacliacutenica de um hospital universitaacuterio Projeto de pesquisa [Validation ofnursing outcomesmdashNursing Outcomes Classification-NOC according tothe clinical practice in a university hospital Research project] Univer-sidade Federal do Rio Grande do Sul Porto Alegre Rio Grande do SulBrasil

Aquino F M Lemos M C M Silva T R amp Christoffel M M (2008) Aproduccedilatildeo cientiacutefica nacional sobre os direitos da crianccedila hospitalizada[The national scientific production about on the rights of the hospitalizedchild] Revista Eletrocircnica de Enfermagem 10(3) 796ndash804 Retrievedfrom httpwwwfenufgbrrevistav10n3pdfv10n3a25pdf

Azevecircdo A V S (2011) O brincar da crianccedila com cacircncer no hospital anaacuteliseda produccedilatildeo cientiacutefica [The play of children with cancer in hospitalsAnalysis scientific production] Estudos de Psicologia 28(4) 565ndash572Retrieved from httpwwwscielobrpdfestpsiv28n415pdf

Beltratildeo B A Silva V M Arauacutejo T L amp Lopes M V O (2011) Clinicalindicators of ineffective breathing pattern in children with congenitalheart diseases International Journal of Nursing Knowledge 22(1) 4ndash12

Branco A U (2005) Peer interactions language development and meta-communication Culture amp Psychology 11(4) 415ndash430

Brasil Ministeacuterio da Sauacutede (2002) Sauacutede da crianccedila acompanhamento docrescimento e desenvolvimento infantil [Child health Monitoring of childgrowth and development] Brasiacutelia Retrieved from httpbvsmssaudegovbrbvspublicacoescrescimento_desenvolvimentopdf

Carvalho A M amp Begnes J G (2006) Brincar em unidades de atendimentopediaacutetrico aplicaccedilotildees e perspectivas [Play in pediatric care units appli-cations and perspectives] Psicologia em Estudo 11(1) 109ndash117 Retrievedfrom httpwwwscielobrpdfpev11n1v11n1a13pdf

Fehring R (1987) Methods to validate nursing diagnoses Marquette Univer-sity College of Nursing Nursing Faculty Research and PublicationsNursing College of Nursing Faculty Research and Publication Retrievedfrom httpepublicationsmarquetteeducgiviewcontentcgiarticle=1026ampcontext=nursing_facampseiredir=1search=rdquoMethods+to+validate+nursing+diagnoses+Heart+Lung

Haiat H Bar-Mor G amp Shochat M (2003) The world of the child A worldof play even in the hospital Journal of Pediatric Nursing 18(3) 209ndash214

Head B J Aquilino M L Johnson M Reed D Maas M amp Moorhead S(2004) Content validity and nursing sensitivity of community-level out-comes from the Nursing Outcomes Classification (NOC) Journal ofNursing Scholarship 36(3) 251ndash259

Head B J Maas M amp Johnson M (2003) Validity and community-healthnursing sensitivity of six outcomes for community health nursing witholder clients Public Health Nursing 20(5) 385ndash398

Herdman T H (2009) Nursing diagnoses Definitions and classifications2009ndash2011 Hoboken NJ Wiley Blackwell

Horta W A (1979) Processo de Enfermagem [Nursing process] Satildeo PauloSP EPU

Jansen M F Santos R M amp Favero L (2010) Benefiacutecios da utilizaccedilatildeo dobrinquedo durante o cuidado de enfermagem prestado agrave crianccedila hospi-talizada [Benefits from the use of toys during nursing care delivered tohospitalized children] Revista Gauacutecha de Enfermagem 31(2) 247ndash253Retrieved from httpwwwscielobrpdfrgenfv31n207pdf

Junior A L C Coutinho S M G amp Ferreira R S (2006) Recreaccedilatildeoplanejada em sala de espera de uma unidade pediaacutetrica efeitos compor-tamentais [Planned recreation in the waiting room of a pediatric unitBehavioral effects] Paideacuteia 16(33) 111ndash118

Junqueira M F P S (2003) A matildee seu filho hospitalizado e o brincar umrelato de experiecircncia [Mother hospitalized child and playing An expe-rience report] Estudos em Psicologia (Natal) 8(1) 193ndash197 Retrievedfrom httpwwwscielobrpdfepsicv8n117250pdf

Kiche M T amp Almeida F A (2009) Therapeutic toy strategy for painmanagement and tension relief during dressing change in children ActaPaulista de Enfermagem 22(2) 125ndash130 Retrieved from httpwwwscielobrpdfapev22n2en_a02v22n2pdf

Leite T M C amp Shimo A K K (2007) O brinquedo no hospital uma anaacuteliseda produccedilatildeo acadecircmica dos enfermeiros brasileiros [The toy in thehospital An analysis of the Brazilian Nursesrsquo Academic Production]


91

Escola Anna Nery Revista de Enfermagem 11(2) 343ndash350 Retrieved fromhttpwwwscielobrpdfeanv11n2v11n2a25pdf

Lima R A G Azevedo E F Nascimento L C amp Rocha S M M (2009) Theart of Clown theater in care for hospitalized children Revista da Escolade Enfermagem da USP 43(1) 186ndash193 Retrieved from httpwwwscielobrpdfreeuspv43n1en_24pdf

Maia E B S Ribeiro C A amp Borba R I H (2011) Understanding nursesrsquoawareness as to the use of therapeutic play in child care Revista daEscola de Enfermagem da USP 45(4) 839ndash846 Retrieved from httpwwwscielobrpdfreeuspv45n4en_v45n4a07pdf

Martins M R Ribeiro C A Borba R I H amp Silva C V (2001) Protocolo depreparo da crianccedila preacute-escolar para a punccedilatildeo venosa com a utilizaccedilatildeo dobrinquedo terapecircutico [Protocol for the preparation of preschool chil-dren to venous puncture using therapeutic play] Revista Latino-Americana de Enfermagem 9(2) 76ndash85 Retrieved from httpwwwscielobrpdfrlaev9n211518pdf

Melo R P Moreira R P Fontenele F C Aguiar A S C Joventino E S ampCarvalho E C (2011) Criteacuterios de seleccedilatildeo de experts para estudos devalidaccedilatildeo de fenocircmenos de enfermagem [Criteria for selection ofexperts for validation studies of nursing phenomena] Revista da Rede deEnfermagem do Nordeste 12(2) 424ndash431 Retrieved from httpwwwrevistareneufcbrvol12n2_pdfa26v12n2pdf

Moorhead S Johnson M Maas M L amp Swanson E (2010) Classificaccedilatildeodos Resultados de Enfermagem [Nursing Outcomes Classification(NOC)] Oxford UK Elsevier

Motta A B amp Enumo S R F (2004) Brincar no hospital estrateacutegia deenfrentamento da hospitalizaccedilatildeo infantil [Playing in the hospital Copingstrategy with childhood hospitalization] Psicologia em Estudo 9(1)19ndash28

Oliveira L D B Gabarra M L Marcon C Silva J L C amp Macchiaverni J(2009) A brinquedoteca hospitalar como fator de promoccedilatildeo no desen-volvimento infantil relato de experiecircncia [The playroom hospital as afactor in promoting children development Experience report] RevistaBrasileira de Crescimento e Desenvolvimento Humano 19(2) 306ndash312

Oliveira R R amp Oliveira I C S (2008) Os doutores da alegria na unidade deinternaccedilatildeo pediaacutetrica experiecircncias da equipe de enfermagem [Theclown doctors in a pediatric unit of internment Experiences of thenursing staff] Escola Anna Nery Revista Enfermagem 12(2) 230ndash236Retrieved from httpwwwscielobrpdfeanv12n2v12n2a05pdf

Paula C C Ravelli A P X Zinn L R amp Motta M G C (2002) Cuidado deenfermagem na aventura do desenvolvimento infantil reflexotildees sobre oluacutedico no mundo da crianccedila Cogitare Enfermagem 7(2) 30ndash34

Queiroz N L N Maciel D A amp Branco A U (2006) Brincadeira e desen-volvimento infantil um olhar sociocultural construtivista [Play and childdevelopment A sociocultural constructivist approach] Paideacuteia cadernosde Psicologia e Educaccedilatildeo 16(34) 169ndash179 Retrieved from httpwwwscielobrpdfpaideiav16n34v16n34a05pdf

Scherb C A Stevens M S amp Busman C (2007) Outcomes related todehydration in the pediatric population Journal of Pediatric Nursing22(5) 376ndash382

Seganfredo D H amp Almeida M A (2010) Produccedilatildeo de conhecimento sobreresultados de enfermagem [Knowledge production about nursing out-comes] Revista Brasileira de Enfermagem 63(1) 122ndash126 Retrieved fromhttpwwwscielobrpdfrebenv63n1v63n1a20pdf

Seganfredo D H amp Almeida M A (2011) Nursing outcomes content valida-tion according to Nursing Outcomes Classification (NOC) for clinicalsurgical and critical patients Revista Latino-Americana de Enfermagem19(1) 34ndash41 Retrieved from httpwwwscielobrpdfrlaev19n106pdf

Strasburg A C Pintanel A C Gomes G C amp Mota M S (2011) Cuidado deenfermagem a crianccedilas hospitalizadas percepccedilatildeo de matildees acompan-hantes [Nursing care of hospitalized children Perception of escortmothers] Revista Enfermagem UERJ 19(2) 262ndash267 Retrieved fromhttpwwwfacenfuerjbrv19n2v19n2a15pdf

Valladares A C A amp Silva M T (2011) A arteterapia e a promoccedilatildeo dodesenvolvimento infantil no contexto da hospitalizaccedilatildeo [Art therapy andchild development in a hospitalization context] Revista Gauacutecha Enferma-gem 32(3) 443ndash450 Retrieved from httpwwwscielobrscielophppid=S1983-14472011000300002ampscript=sci_arttext


92

nication and building a cultural understanding (Branco2005) These activities may help build and promote a betterunderstanding of child development (Queiroz Maciel ampBranco 2006)

It is well known that the experience of staying in thehospital often makes children stop participating in recre-ational activities Studies show that the hospital environ-ment is in itself stressful which may also have apsychological impact on the child (Carvalho amp Begnes 2006Jansen Santos amp Favero 2010)

In this sense nurses use the NANDA-I nursing diagnosisfor deficient diversional activity (DDA) (00097) The diag-nosis is defined as ldquo[d]ecreased stimulation from (or inter-est or engagement in) recreational or leisure activitiesrdquo Ithas two defining characteristics patientsrsquo statementsregarding boredom (eg I wish there was something to doto read) usual hobbies cannot be undertaken in the hospitalenvironment and the related environmental factor of lackof diversional activity (Herdman 2009) Using the nursingdiagnosis to evaluate the situation of hospitalized childrenthe nurse is able to carry out interventions aimed at obtain-ing more positive outcomes

Literature on nursing contains a growing number of ref-erences about recreation of hospitalized children A reviewfound that most studies focus on the effects of playing onchildren but recreation is still a recent practice and it isnecessary to strengthen it as an intervention valued likeany other scientific knowledge since it is considered essen-tial to child development and well-being (Leite amp Shimo2007 Maia Ribeiro amp Borba 2011)

In this context Brazilian nurses are striving to identifyoutcomes that are sensitive to nursing practices TheNursing Outcomes Classification (NOC) is being widely usedin this context to describe the health status behavior orperception of an individual family or community measuredon a continuum and as a response to one or more nursinginterventions (Moorhead Johnson Maas amp Swanson2010) In pediatrics there is a noteworthy Brazilian studythat investigated the nursing outcomes and NOC indicatorswith or without the presence of ineffective breathingpattern diagnosis in children with congenital cardiopathies(Beltratildeo Silva Araujo amp Lopes 2011) A pilot study investi-gated the nursing outcomes of dehydrated children fromhospital admission to release The study showed significantchanges in seven out of eight outcomes (Scherb Stevens ampBusman 2007)

The assessment of nursing interventions is essential forthe improvement of healthcare quality NOC is useful forthe evaluation of the impact of nursing care The classifica-tion also helps rationalize nursing practices and achievegreater benefits from them (Seganfredo amp Almeida 2010)Studies that evaluate the results of nursing practice areessential to implement this classification in clinical practiceIn this case the validation of the nursing results content isrecommended to confirm whether the indicators representthe results of nursing interventions for a diagnosis ofnursing (Seganfredo amp Almeida 2011)

In southern Brazil the research project ldquoValidaccedilatildeo deResultados de Enfermagem segundo a Nursing OutcomesClassificationmdashNOC na praacutetica cliacutenica de um hospital univer-sitaacuteriordquo (Validation of Nursing Outcomes using the NursingOutcomes ClassificationmdashNOC in clinical practice at a uni-versity hospital) is being carried out to validate selectednursing outcomes using the NOCndashNANDA-I relationship forthe most frequent nursing diagnosis in patients under dif-ferent types of nursing care (Almeida et al 2008) Thediagnosis of DDA was one of the most frequent in pediat-rics the nursing outcomes for this diagnostic are still underinvestigation Working with a classification that measuresoutcomes is important as it permits the identification ofimpact quality efficacy and cost of nursing interventionsin patient care

Purpose

The goal of this study is to validate the NOC for hospi-talized children with a nursing diagnosis of DDA

Methods

We carried out a study aiming to validate content Weperformed the study using an adapted version of theFehring (1987) model since there are no specific criteria tosupport the validation of nursing outcomes (Melo et al2011) This adaptation refers to the validation of NOC indi-cators instead of characteristics that define a nursing diag-nosis and the criteria used to include the experts for thisvalidation The outcome content validation adapted fromthe model of diagnosis content validation proposed byFehring has been used in various studies (Head et al 2004Head Maas amp Johnson 2003)

The study was carried out in a university hospital insouthern Brazil Since 2000 the hospital has applied a com-puterized nursing process for medical history and physicalexamination nursing diagnosis healthcare prescriptionand evolutionevaluation The system used at the hospitalwas structured based on the theory of basic human needsput forth by Wanda Horta (1979) It takes into considerationthe NANDA-I Nursing Dx Nursing Interventions Classifica-tion (NIC) nursing care and the clinical practice of nursesThe evaluation of patients does not follow a standardizedterminology such as the NOC

The study included registered nurses (RNs) from thepediatric nursing services The service employs 57 RNs infour units clinical and surgical admission hematologyoncology and intensive care These services care for pedi-atric patients aged 30 days to 14 years and up to the age of18 years in some specific situations and have 109 bedsavailable

The pediatric units in this study are characterized byconcentrating their attention on the development of themethodology of care focusing on the child and the familyThe guiding premises are the ParentsChildren Joint Stay


86









Results










months3 (4285)



NP nursing process


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Results










months3 (4285)



NP nursing process


87




Discussion















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Discussion















88














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References





















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Documents

Nursing Outcomes for Brazilian Pediatric Patients Hospitalized With Deficient Diversional Activity