ORIGINAL ARTICLE

Advanced Nursing Process quality: Comparing the International

Classification for Nursing Practice (ICNP) with the NANDA-
International (NANDA-I) and Nursing Interventions Classification
(NIC)
Eneida Rejane Rabelo-Silva, Ana Carla Dantas Cavalcanti, Maria Cristina Ramos Goulart Caldas,
Am
alia de F
atima Lucena, Miriam de Abreu Almeida, Graciele Fernanda da Costa Linch, Marcos
Barragan da Silva and Maria M€ uller-Staub

Aims and objectives. To assess the quality of the advanced nursing process in
nursing documentation in two hospitals. What does this paper contribute
Background. Various standardised terminologies are employed by nurses world- to the wider global clinical
wide, whether for teaching, research or patient care. These systems can improve community?
the quality of nursing records, enable care continuity, consistency in written com-  Studies comparing the quality of
munication and enhance safety for patients and providers alike. nursing records as a function of
Design. Cross-sectional study. different standardised terminolo-
gies have not been published
Methods. A total of 138 records from two facilities (69 records from each facil-
hitherto.
ity) were analysed, one using the NANDA-International and Nursing Interven-  From a quality standpoint, lack
tions Classification terminology (Centre 1) and one the International of consistency influences care
Classification for Nursing Practice (Centre 2), by means of the Quality of Diag- continuity, nursing process docu-
noses, Interventions, and Outcomes instrument. Quality of Diagnoses, Interven- mentation and patient safety.
tions, and Outcomes scores range from 0–58 points. Nursing records were dated The outcomes of such investiga-
tions can be used to safely define
2012–2013 for Centre 1 and 2010–2011 for Centre 2.
an optimal strategy to make
Results. Centre 1 had a Quality of Diagnoses, Interventions, and Outcomes score nurses’ work visible and to eval-
of 35
46 (6
45), whereas Centre 2 had a Quality of Diagnoses, Interventions, uate nursing care quality and
and Outcomes score of 31
72 (4
62) (p < 0
001). Centre 2 had higher scores in effectiveness.
the ‘Nursing Diagnoses as Process’ dimension, whereas in the ‘Nursing Diagnoses
as Product’, ‘Nursing Interventions’ and ‘Nursing Outcomes’ dimensions, Centre

Authors: Eneida Rejane Rabelo-Silva, ScD, RN, Professor, Gradu-
ate Program in Nursing at Federal University of Rio Grande do Sul
and Hospital de Cl
ınicas de Porto Alegre and Grupo de Estudo e
Pesquisa em Enfermagem no Cuidado ao Adulto e Idoso (GEPE-
CADI), Porto Alegre, RS; Ana Carla Dantas Cavalcanti, ScD, RN,
Professor, Universidade Federal Fluminense, Niter
oi, RJ; Maria
Cristina Ramos Goulart Caldas, RN, Nurse of Instituto Nacional
do C^ancer (HC III), Rio de Janeiro, RJ; Am
alia de F
atima Lucena,
ScD, RN, Professor, Graduate Program in Nursing at Federal
University of Rio Grande do Sul and Hospital de Cl
ınicas de Porto
Alegre and Grupo de Estudo e Pesquisa em Enfermagem no Cui-
dado ao Adulto e Idoso (GEPECADI), Porto Alegre, RS; Miriam de
Abreu Almeida, ScD, RN, Professor, Graduate Program in Nursing
at Federal University of Rio Grande do Sul and Hospital de Cl
ıni-
cas de Porto Alegre and Grupo de Estudo e Pesquisa em
Enfermagem no Cuidado ao Adulto e Idoso (GEPECADI), Porto
Alegre, RS; Graciele Fernanda da Costa Linch, ScD, RN, Professor,
Universidade Federal de Ci^encias da Sa

ude de Porto Alegre, Porto
Alegre, RS; Marcos Barragan da Silva, MSc, RN, PhD Student,
Graduate Program in Nursing at Federal University of Rio Grande
do Sul and Hospital de Cl
ınicas de Porto Alegre and Grupo de
Estudo e Pesquisa em Enfermagem no Cuidado ao Adulto e Idoso
(GEPECADI), Porto Alegre, RS, Brazil; Maria M€ uller-Staub, PhD,
RN, FEANS, Professor, Nursing Projects, Research and Innovation
(Switzerland) & Hanze University, Groningen, the Netherlands
Correspondence: Eneida Rejane Rabelo da Silva, Professor, Escola
de Enfermagem da Universidade Federal do Rio Grande do Sul,
Rua: S~ao Manoel, 963 – Rio Branco, Porto Alegre, RS 90620-110,
Brazil. Telephone: +55 51 33598017/33598657.
E-mails: eneidarabelo@gmail.com; esilva@hcpa.edu.br

© 2016 John Wiley & Sons Ltd

Journal of Clinical Nursing, 26, 379–387, doi: 10.1111/jocn.13387 379
ER Rabelo-Silva et al.

1 exhibited superior performance; acceptable reliability values were obtained for

both centres, except for the ‘Nursing Interventions’ domain in Centre 1 and the
‘Nursing Diagnoses as Process’ and ‘Nursing Diagnoses as Product’ domains in
Centre 2.
Conclusion. The quality of nursing documentation was superior at Centre 1,
although both facilities demonstrated moderate scores considering the maximum
potential score of 58 points. Reliability analyses showed satisfactory results for
both standardised terminologies.
Relevance to clinical practice. Nursing leaders should use a validated instrument
to investigate the quality of nursing records after implementation of standardised
terminologies.

Key words: classification, International Classification for Nursing Practice,

NANDA-International, Nursing Interventions Classification, nursing process,
nursing records, Quality of Diagnoses, Interventions, and Outcomes instrument

Accepted for publication: 29 April 2016

nursing as a scientific discipline (Jones et al. 2010, Keenan

Introduction
In response to criticism regarding the lack of content
and validity of the traditional nursing process, the so-
called advanced nursing process was developed. Instead
of using free-text terms unsupported by evidence to for-
mulate nursing diagnoses, the advanced nursing process
uses standardised, validated, evidence-based concepts that
are defined in specific nursing classifications. In other
words, the advanced nursing process consists of defined,
evidence-based concepts and includes valid assessment
tools and well-defined nursing diagnoses, interventions
and outcomes that are standardised and explained in sci-
entifically based nursing classifications (M€ uller-Staub
et al. 2015). Any method used to implement the
advanced nursing process must be context-appropriate
and able to guide clinical practice. Most commonly, this
process is taught and implemented by means of standard-
ised nursing languages (Ackley et al. 2008, Ackley &
Ladwig 2014).
Standardised nursing languages (SNLs) are attempts to
create consistency in the vocabulary used by nurses and
offer classification-based structures for a variety of elements
involved in care practices. SNLs support professional
growth and stability by fostering critical thinking as part of
the decision-making process for nursing diagnoses, interven-
tions and outcomes. SNLs allow the proper keeping and
refinement of nursing documentation as part of the elec-
tronic health record (EHR), thus increasing visibility of
et al. 2013).
Background
The use of SNLs has been described as a contributing factor
to the quality of nursing, as it enables care continuity
through consistency in communication and documentation
of information. This, in turn, increases safety for patients
and providers alike. Furthermore, SNLs facilitate goal and
outcome-oriented planning and evaluations of the advanced
nursing process in clinical practice (M€ uller-Staub et al.
2008b, Saranto & Kinnunen 2009, Linch et al. 2010).
Another relevant reason to use SNLs is technological
advancement and the need for EHR implementation. The
use and permanent storage of EHRs, particularly when
combined with SNLs, allows to capture, represent, access,
communicate and research nursing documentation informa-
tion (Keenan et al. 2008, 2012, 2013, Jones et al. 2010,
Kelley et al. 2011, Brokel et al. 2012).
The outcomes achieved by patients are the most impor-
tant indicator of quality in health care, of which nursing
care is an integral part. Health care communicated in
unspecific, unclear wording leads to inconsistencies due to
divergences in naming patients’ care needs (nursing diag-
noses), nursing interventions and treatment goals between
providers, teams, sectors or facilities. Unclear or nonprecise
documentation and communication leads to missing care
effectiveness, and evaluations of the care given are

© 2016 John Wiley & Sons Ltd

380 Journal of Clinical Nursing, 26, 379–387
Original article
hampered (Koczmara et al. 2005, 2006, Wang et al. 2011,
Zegers et al. 2011). SNLs aim to clearly name evidence-
based nursing diagnoses, interventions and outcomes and
thus allow the development of consented guidelines (H€ ayri-
nen et al. 2010, Jones et al. 2010, Paans et al. 2010).
For these reasons, the use of SNLs in the advanced nurs-
ing process has mobilised nurses worldwide to face the
challenge of making the elements of clinical nursing prac-
tice universal (H€ayrinen et al. 2010, Kelley et al. 2011,
Wang et al. 2011). In choosing an SNL including the
advanced nursing process, nurses and their employers take
a stance towards keeping patient records based on their
knowledge and experience. Not choosing the advanced
nursing process is a decision that may lead to omission of
data that would otherwise play an important stewardship
role in nursing, as nursing records that do not follow a sys-
tematic methodology can jeopardise the quality of patient
care (H€ayrinen et al. 2010, Tastan et al. 2014).
Therefore, the development of scientific evidence in the
field of nursing requires utilisation of the advanced nursing
process based on SNLs, which enable the use of universal,
validated concepts and interpretation of nursing records by
different providers at different institutions (Keenan et al.
2008, Anderson et al. 2009, Kelley et al. 2011). Since
1970s, investigators have worked to classify nursing phe-
nomena for the purposes of electronic documentation.
Worldwide, these researchers assembled in associations
and/or groups with the intent of developing and investigat-
ing SNLs. Examples include NANDA-International
(NANDA-I), the Center for Nursing Classification and
Clinical Effectiveness (CNC), the International Council of
Nursing (ICN), the Association for Common European
Nursing Diagnoses, Interventions and Outcomes (ACEN-
DIO) and the Asociaci
on Espa~ nola de Nomenclatura, Tax-
onom
ıa y Diagn
osticos de Enfermer
ıa (AENTDE), among
others with similar purposes (Tastan et al. 2014).
Studies driven by these groups and by other investigators
worldwide have strengthened and improved SNLs, which
can be understood as systems of labels of the three nursing
elements of diagnosis, outcomes and interventions. These
systems include NANDA-I (the most used diagnoses classifi-
cation worldwide) (Tastan et al. 2014), the Nursing Out-
comes Classification (NOC) and the Nursing Interventions
Classification (NIC), which provide SNL for nursing out-
comes and interventions respectively (Head et al. 2011,
Kelley et al. 2011, Johnson et al. 2012).
Some systems propose a combination of all three ele-
ments, such as the Omaha System, the Perioperative Nurs-
ing Data Set (PNDS) and the Clinical Care Classification/
Home Health Care Classification (CCC/HHCC) (Tastan
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 26, 379–387
Advanced nursing process quality by the Q-DIO
et al. 2014) or the NANDA-I linked with NIC and NOC
(NNN) (Johnson et al. 2012, Ackley & Ladwig 2014). On
the other hand, the International Classification for Nursing
Practice (ICNP) includes two of three elements: nursing
diagnoses and interventions (Coenen et al. 2012).
Various SNLs are employed by nurses worldwide,
whether for teaching, research and/or patient care (M€ uller-
Staub et al. 2015). Therefore, choosing an SNL poses a
challenge for nurse leaders when plans for the implementa-
tion of the advanced nursing process and EHR documenta-
tion have to be made. Up to now, there has been little
research on the quality of SNL application in practice.
Questions remain as to whether one classification is supe-
rior for clinical documentation of the advanced nursing
process or which classification best adapts to the character-
istics of a facility.
The ICNP proposes a wide-ranging, understandable refer-
ence terminology that can adapt to multiple purposes in dif-
ferent countries and be regarded as a significant resource for
the description of nursing practices. It does not contain
defined nursing diagnoses including related factors and defin-
ing characteristics; rather, the ICNP develops catalogues
(nursing data subsets) for specified health situations that are
used in building health information systems (Hardiker &
Rector 2001, Coenen et al. 2012, Tastan et al. 2014).
However, it currently employs a seven-axis model. Estab-
lishing a nursing diagnosis (ND) requires that the clinical
nurse select at least one term from two axes, namely, the
axes ‘focus’ and ‘judgement’. Focus is the area of relevance
to nursing practice, whereas judgement is the clinical opin-
ion related to the selected focus (Comit^e Internacional de
Enfermeiros 2011). NANDA-I promotes clinical reasoning
and diagnostic precision by describing each ND as a con-
cept including defining characteristics and related factors
(Herdman & Kamitsuru 2014). Stating a ND in practice
requires identification of the relevant data (defining charac-
teristics and related or risk factors) collected during nursing
assessments (interview, physical examination, laboratory
and other test results) for an evidence-based diagnostic vali-
dation. In NANDA-I, a ND is a concept constructed by
means of a multi-axial system consistent with the ISO refer-
ence terminology model (NANDA-I 2015). As in the ICNP
(Comit^e Internacional de Enfermeiros 2011), the focus and
judgement axes play an essential role in stating ND for
patients. The NIC is a wide-ranging intervention classifica-
tion encompassing the entire domain of nursing as a disci-
pline and representing all areas of nursing practice
(NANDA-I 2015).
Despite the importance of SNLs as a means of improving
the quality of nursing records and supporting nursing
381
ER Rabelo-Silva et al.
practice based on critical thinking and EHR development,
we found few studies conducted in clinical settings. Evalua-
tions on the two most widely used SNLs to compare the
quality of records using one or the other are missing. The
relevance of this study is its focus on measuring the quality
of the advanced nursing process based on the NANDA-I/
NIC and ICNP classifications in two Brazilian health facili-
ties.
The Quality of Diagnoses, Interventions, and Outcomes
(Q-DIO) (M€ uller-Staub et al. 2008a,b, M€ uller-Staub et al.
2009, Saranto & Kinnunen 2009), an instrument recently
validated for use in Brazil (Linch et al. 2015), allows to
bridge this knowledge gap.
Hence, the results of this study provide evidence on the
quality of nursing records kept with the NANDA-I/NIC and
ICNP standardised terminologies. Simultaneously, it pro-
vides inputs to support selection of the SNL most likely to
ensure consistency in communication and documentation,
thus ensuring patient and provider safety and facilitating
goal- and outcome-oriented planning of clinical practice.
The study
Aims and objectives
To assess the quality of the advanced nursing process in
nursing documentation in two hospitals, one using the
NANDA-I and NIC terminology and the other using ICNP,
by means of the Q-DIO instrument.
Design
A cross-sectional study was carried out at two Brazilian
hospitals.
Sample/Participants
Data were collected from the health records of oncology
patients with breast neoplasms who had been hospitalised
in the clinical or surgical wards of both study facilities for
at least four consecutive days. These facilities were selected
because one uses EHRs in combination with the NANDA-I
and NIC (Centre 1), whereas the other keeps handwritten
nursing records based on the ICNP (Centre 2). Both are
teaching hospitals with research centres and both are
accredited by Joint Commission International (JCI), a net-
work of health facilities recognised for their excellence in
patient care.
The study included nursing records dated 2012–2013
for Centre 1 and 2010–2011 for Centre 2. Selection of
382
these periods was determined by the timing of the JCI
accreditation process at each facility, as both had con-
ducted training activities pertaining to nursing records in
the preceding years. Handwritten records that were illegi-
ble to the investigators were excluded from the sample.
Electronic records that did not correspond to patients with
a clinical diagnosis of malignancy for the aforementioned
periods and records from off-site patients were excluded.
First, the health record numbers of patients admitted to
the study centres with malignant neoplasms and otherwise
eligible for the study were compiled in a list. This list was
then used for randomisation in the Statistical Package for
the Social Sciences (SPSS) 20.0, version software (Chicago,
Ilinois, USA), taking into account a 20% attrition rate.
Two illegible manual records and seven records that did
not correspond to a diagnosis of malignancy had to be
excluded from the sample.
To prevent bias during Q-DIO completion, data collec-
tion was carried out at both facilities by the same
researcher, who had been previously trained to administer
the Brazilian version of the instrument.
Initially, we conducted a pilot study consisting of appli-
cation of the Q-DIO to 10 health records from each centre
by two investigators, which yielded a j coefficient of 0
85.
A noninferiority analysis was used to calculate the sample
on the basis of a standard deviation of 2
8 for Centre 1 and
3
72 for Centre 2.
The sample size was estimated with WINPEPI v11.32, ver-
sion, Jerusalem, Israel (2011). For a statistical power of
90%, a significance level of 2
5% (or 0
025) and a two-
point difference in scores between centres, the sample size
was calculated as 138 health records (69 per facility).
Data collection
After sample size calculation and randomisation of records,
the investigators collected information contained in the
nursing records of history and physical examination (com-
pleted at the time of patient admission) and assessed the
progress notes kept for the four subsequent days. The nurs-
ing diagnoses, interventions, prescriptions and outcomes
documented during this period in these notes were evalu-
ated.
Centre 1 used the SOIC (subjective, objective, inter-
pretation and management) approach as the standard
format for daily record-keeping, whereas Centre 2 used
the SOAP (subjective, objective, assessment and plan)
format.
To assess the quality of the advanced nursing process in
nursing documentation, we employed the Brazilian version
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 26, 379–387
Original article Advanced nursing process quality by the Q-DIO

of the Q-DIO (Linch et al. 2015), following the guideline
for Q-DIO application. This questionnaire consists of 29
items subdivided into four scales, each of which is scored
on a three-point scale (0 = not achieved; 1 = partially
achieved; 2 = fully achieved), for a minimum score of 0
(zero) and a maximum score of 58 points.
The first subscale, ‘Nursing Diagnoses as Process’,
addresses nursing assessment accuracy and comprises 11
items with a maximum score of 22; the optimal score is 2
points per item. This subscale evaluates issues related to the
patient assessment and interview. The second subscale,
‘Nursing Diagnoses as Product’, comprises eight items for a
maximum score of 16. This subscale addresses the accuracy
of the nursing diagnostic label, definition, defining character-
istics and related factors. The third subscale, ‘Nursing Inter-
ventions’, comprises three items with a maximum score of 6;
again, the optimal score is 2 points per item. This subscale
addresses intervention effectiveness by asking if the interven-
tion affects the aetiology of the ND including planning and
verification after performance. The fourth subscale, ‘Nursing
Outcomes’, comprises seven items for a maximum score of
tests were used to compare Cronbach’s a coefficients
between the facilities. p-Values < 0
05 were considered
significant.
Results
Total Q-DIO score
A total of 69 health records from each facility were exam-
ined for evaluation. Figure 1 shows the mean total Q-DIO
score (maximum: 58). Centre 1, which uses NANDA-I/NIC
classifications, had a Q-DIO score of 35
46  6
45,
whereas Centre 2, which uses the ICNP, had a Q-DIO
score of 31
72  4
62 (p < 0
001).
Q-DIO dimension scores
Table 1 shows significant differences between facilities in Q-
DIO scores across all dimensions. In the ‘Nursing Diagnoses
60

14 and an optimal score of 2 points per item. This subscale

50
measures the quality of nursing-sensitive patient outcomes,
respectively, the achievement nursing goals as described in 40
Q-DIO score

the progress notes.

For assessment of interobserver agreement, 20% of 30
records from each facility were randomly selected for evalu-
20
ation by a second investigator at Centre 1 and a third
investigator at Centre 2. Both investigators were trained by
10
the researcher who originally validated the Q-DIO. Interob-
server agreement ensures that an instrument yields similar 0
results when applied by different investigators to evaluate Center 1 Center 2

the same records. Figure 1 Quality of Diagnoses, Interventions, and Outcomes scores
from the two centres. *Student’s t-test (p < 0.001).

Ethical considerations

The local Research Ethics Committee approved this study,

Table 1 Comparison between scores for Centre 1 (NANDA-Inter-
and all investigators signed a data use agreement form. national/Nursing Interventions Classification) and Centre 2 (Inter-
national Classification for Nursing Practice) by Quality of
Diagnoses, Interventions, and Outcomes (Q-DIO) dimension
Data analysis
Q-DIO dimension
Data were organised and analysed in SPSS 20.0, version. (Brazilian version) Centre 1 Centre 2 p*
Continuous variables were expressed as means and stan-
Nursing diagnoses 9
65  3
98 11
09  2
68 0
015
dard deviation, as appropriate to the data distribution. as process
Q-DIO results were expressed considering the maximum Nursing diagnoses 13
09  2
16 9
13  1
17 <0
001
total score of 58. The two facilities were compared by as product
means of Student’s t-test. The j statistic was used for Nursing interventions 5
41  0
82 5
04  1
04 0
026
analysis of inter-rater agreement, and the prevalence and Nursing outcomes 7
32  2
66 6
46  2
27 0
044

bias-adjusted j (PABAK-OS) to verify confidence. Cron- Mean  standard deviation.

bach’s a was applied to analyse reliability. Fisher–Bonett *Student’s t-test.

© 2016 John Wiley & Sons Ltd

Journal of Clinical Nursing, 26, 379–387 383
ER Rabelo-Silva et al.
as Process’ dimension, Centre 2 (ICNP) had higher scores,
whereas in the ‘Nursing Diagnoses as Product’, ‘Nursing
Interventions’ and ‘Nursing Outcomes’ dimensions, Centre 1
(NANDA-I/NIC) exhibited superior performance.
Interobserver agreement
The j coefficient between investigators was 0
895 (95% CI
0
959–1
0401) for Centre 1 and 0
938 (95% CI 0
901–
0
979) for Centre 2.
Reliability of the Q-DIO instrument between facilities
and standardised nursing terminologies
Table 2 lists the results of reliability analysis of all four Q-
DIO domains and a comparison between the two centres.
Acceptable values were obtained for both centres (a > 0
7),
except for the ‘Nursing Interventions’ domain in Centre 1
and the ‘Nursing Diagnoses as Process’ and ‘Nursing Diag-
noses as Product’ domains in Centre 2.
Discussion
This study presents the first evidence for the quality of nurs-
ing records kept using the NANDA-I/NIC and ICNP stan-
dardised terminologies at two different hospitals. According
to the results, records at the facility that employs the
NANDA-I/NIC classifications demonstrated statistically
superior results regarding application of the advanced nurs-
ing process. Both facilities demonstrated moderate scores
considering the maximum potential score of 58 points.
Although the Q-DIO does not provide a hierarchical
scale for classification of total scores, both facilities
demonstrated moderate scores (Centre 1, 35
46; Centre
2, 31
72). This reveals some difficulty in use of the
NANDA-I/NIC and ICNP standardised terminologies by
Table 2 Comparison of Cronbach’s a coefficients between the
NANDA International (NANDA-I)/Nursing Interventions Classifi-
cation (NIC) and International Classification for Nursing Practice
(ICNP) terminologies by Quality of Diagnoses, Interventions, and
Outcomes (Q-DIO) domain (Brazilian version)
Centre 1
NANDA-I, Centre 2 Fisher–Bonett
Q-DIO domains NIC ICNP test
Nursing diagnosis 0
762 0
519 0
003
(ND) as process
ND as product 0
834 0
532 <0
001
Nursing interventions 0
599 0
799 0
977
Nursing outcomes 0
847 0
810 0
209
384
clinical nurses. This finding supports the results of a
descriptive study in which the NANDA-I, NIC and
NOC classifications were compared with the ICNP by
analysing the notes of 24 nurses from a single clinical
case. Greater diagnostic accuracy was observed in the
group that employed the NANDA-I as compared with
nurses who used the ICNP. However, both groups
obtained low diagnostic accuracy, regardless of the ter-
minology employed (Morais 2014). Several studies indi-
cate that nurses need training to apply the advanced
nursing process, as it requires diagnostic knowledge and
critical thinking skills (Paans et al. 2010, 2012, Bruy-
lands et al. 2013).
‘Nursing Diagnoses as Process’: Centre 2 (ICNP)
obtained significantly higher scores than Centre 1
(NANDA-I) for this dimension. Although the present study
refers to standardised languages, this Q-DIO dimension
does not address standardised language, as it concerns data
collection formulated as qualitative free text from patients
and their families. In Centre 2, handwritten records were
kept, although a structured form was used for the nursing
history, whereas in Centre 1 a structured, electronic data
collection instrument was applied for both history and
physical examination. In both facilities, collection of these
data is based on a conceptual framework guided by basic
human needs, which regards the individual patient from the
standpoint of psychobiological, psychosocial and psychos-
piritual needs, on which the nursing diagnoses will be based
and formulated at the appropriate stage of the nursing pro-
cess (Horta 1979).
The fact that Centre 2 (ICNP) is a specialised cancer
treatment facility suggests that nurses may have had greater
mastery of the specific oncologic signs and symptoms that
characterise unmet needs found in these patients during
assessment interviews. This could be a possible explanation
for the superior quality observed in the ‘Nursing Diagnoses
as a Process’ dimension at this facility.
It bears stressing that Centre 1 cannot actually be seen
as inferior in terms of this dimension, as an EHR system is
employed that directs the nurse from the history-taking
stage (nursing assessment) to the ND stage, that is, the
diagnostic reasoning and critical thinking process is sup-
ported by the electronic tool, but is not automatically doc-
umented by the system. The data collection phase of
nursing assessment is based on the patient’s basic human
needs, and the electronic system directs the nurse to a
screen that contains diagnostic cues. At the third stage of
the advanced nursing process, the nurse establishes a diag-
nostic decision by the NANDA-I classification. However,
these advanced nursing process phases are not
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 26, 379–387
Original article
automatically documented by the system, as they are con-
sidered part of the decision-making process which nurses
are trained to carry out.
On the other hand, when using the ICNP, the nurse does
not need to establish a cause, nor must she mention the signs
and symptoms that support the diagnosis. The search for diag-
nostic clues is open-ended rather than targeted, as diagnoses
are established according to the linkage of focus and judge-
ment, which may also have explained the higher scores
obtained in this dimension (NANDA-I 2015, Souza et al.
2015).
‘Nursing Diagnoses as Product’: In this dimension, Cen-
tre 1 (NANDA-I) achieved higher quality and reliability as
compared with Centre 2 (ICNP). The NANDA-I classifica-
tion contains required attributes for a ND, such as defining
characteristics and related factors (aetiology) for an actual
diagnosis. By not describing the aetiology (related factor/
risk factor) of diagnoses, the accuracy of ICNP diagnoses is
jeopardised. The missing conceptual definitions and charac-
teristics of ICNP nursing diagnoses preclude systematic
teaching and research of the clinical reasoning process
involved in diagnostic accuracy (Comit^e Internacional de
Enfermeiros 2011, NANDA-I 2015). This minimises and
interferes with nurses’ knowledge-based decision making
for selection of diagnosis-specific, effective nursing interven-
tions, which in turn is a prerequisite to achievement of
high-quality patient outcomes. This finding is reinforced by
the results of the aforementioned study that used a single
clinical case to compare diagnostic accuracy with the
NANDA-I terminology vs. the ICNP. The study on the
ICNP also demonstrated fragility in its ability to establish a
diagnostic reasoning process, generating several labels char-
acterised by little or no diagnostic precision (Morais 2014).
‘Nursing Interventions’ and ‘Nursing Outcomes’: There
were significant differences found in Nursing Interventions as
well as in Nursing Outcomes. Both centres achieved good
scores in the Nursing Interventions dimension, which demon-
strates that the nursing interventions solved or minimised the
cause of the problem that constitutes the aetiology of the nurs-
ing diagnoses. Interventions were clearly prescribed, planned
and performed accordingly and documented after completion
by the nursing staff. Regarding nursing outcomes, scores were
low at both facilities. One may infer that failure to use SNLs
for documentation of the outcomes desired and achieved by
patients after nursing interventions accounted for these low
scores. This highlights the need to ascribe greater value to this
stage of the advanced nursing process by standardised out-
come indicators – for instance, as described in the NOC – as
an essential step in choosing and evaluating desired nursing-
sensitive patient outcomes.
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 26, 379–387
Advanced nursing process quality by the Q-DIO
This lack of evidence to support the influence of SNL use
on patient outcomes or other health care-related outcomes
was also reported in a systematic review of 312 articles
(Tastan et al. 2014).
A previous study regarding the NOC and ICNP standard-
ised languages confirmed the feasibility of NOC, particu-
larly for its comprehensiveness and contributions for
outcome planning and evaluations. The ICNP was less
comprehensive in terms of expected outcomes (Morais
2014).
To date, no other studies have been published on the
advanced nursing process as applied in actual clinical
practice. The present study is the first clinical evalua-
tion to compare these two SNLs in practice, which lim-
its discussion of our findings in the light of previous
research.
Finally, it is possible to relate the highest scores obtained
by Q-DIO in the Centre 1 with the computerised nursing
prescription available. The EHRs provide the search data
and contribute to more accurate clinical decisions.
Limitations
Data for the ‘Nursing Diagnoses as Process’ dimension of
the Q-DIO were collected through the history and physical
examination. In patients who were somnolent, dyspneic,
mechanically ventilated, comatose or otherwise unable to
be interviewed, records pertaining to this assessment were
jeopardised.
Neither of the assessed facilities had implemented the
NOC terminology; this interfered with measurement of
the ‘Nursing Outcomes’ dimension of the Q-DIO instru-
ment.
Although both of the study facilities were teaching hospi-
tals with research centres and both are JCI accredited, the
quality of documentation still might be influenced by the
individual capabilities of nurses. This could be construed as
a limitation to generalising the findings of our study.
Conclusion
The results demonstrate that the quality of the advanced
nursing process in nursing documentation was superior at a
facility in which an electronic record using NANDA-I/NIC
was applied. However, both facilities demonstrated moder-
ate scores considering the maximum potential score of 58
points, and reliability analyses showed satisfactory results
for both standardised terminologies.
In the ‘Nursing Diagnoses as Process’ domain, Cen-
tre 2 demonstrated superior performance than Centre
385
ER Rabelo-Silva et al.

1, whereas for the ‘Nursing Diagnoses as Product’,

‘Nursing Interventions’ and ‘Nursing Outcomes’
Acknowledgement
dimensions, Centre 1 (NANDA-I/NIC) exhibited supe- This work was supported by the Fundo de Incentivo  a Pesquisa
rior performance. e Eventos (FIPE) do Hospital de Cl
ınicas de Porto Alegre.
Regarding reliability, Centre 1 (NANDA-I/NIC) achieved
adequate values on three of the four Q-DIO dimensions,
with an acceptable value for the ‘Nursing Interventions’
Contributions
dimension. Centre 2 (ICNP) achieved satisfactory scores for Study Design: ERRS, MM-S; Data collection and analysis:
two of the four dimensions; scores were deemed unsatisfac- ACDC, MCRG, GFCL, MBS; Manuscript preparation:
tory for the dimensions ‘Nursing Diagnoses as Process’ and ERRS, ACDC, MCRG, AFL, MAA, MM-S.
‘Nursing Diagnoses as Product’.
These findings provide pioneering results on evaluations
Conflict of interest
of the advanced nursing process based on nursing documen-
tation as ascertained by a validated instrument. There is no conflict of interest to declare.

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