The consistent availability of a core set of clinical nursing data is essential to promote quality patient care. Although important work to improve terminology and enhance comparability of data is underway, the efforts do not address the immediate need for useful nursing data sets and valid methods of collection at the point of data entry. The Hands-on Automated Nursing Data System (HANDS) project is dedicated to refining a feasible methodology for gathering, storing, and retrieving a standardized nursing data set. To date the project team has developed and tested a prototype research tool that is automated and contains the structured terminologies (North American Nursing Diagnosis Association, Nursing Outcomes Classification, and Nursing Interventions Classification) to represent nursing diagnoses, outcomes, and interventions, respectively. The Phase I project development activities are reported in this article, along with Phase II and III plans for testing and refining the methodology under actual clinical conditions. Results and lessons learned during Phase I are reported.

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The purpose of our research is to identify a realistic subset of North American Nursing Diagnosis Association (NANDA), Nursing Outcome Classification (NOC), and Nursing Interventions Classification (NIC) terms specific to the home care (HC) setting. A subset of 89 NOC outcomes were identified for study in HC through a baseline survey. Three research assistants then observed the care of 258 patients to whom the 89 NOC outcomes applied and recorded the associated NANDA and NIC terms. Follow-up surveys and focus groups were conducted with the nurses and research assistants. There were 81 different NANDA and 226 NIC labels used to describe study patients’ care. Only 36 of the 89 NOC labels studied were deemed clinically useful for HC. We found that expert opinion about terminology usage before actual experience under practice conditions is unreliable.

O estudo possui o objetivo principal de ampliar a compreensão sobre a produção do “agir em competência” para o cuidado especializado na atenção à saúde bucal. A abordagem metodológica utilizou análises qualitativas e quantitativas. Um questionário online com 32 questões organizadas em cinco blocos temáticos foi respondido de forma anônima por estagiários de Odontologia nos serviços do Sistema Único de Saúde. Categorias temáticas e componentes analisadores foram sistematizados: protocolos, campos de estágio, atividades de educação à distância e dinâmicas pedagógicas. Os dados quantitativos foram analisados pela freqüência das respostas fechadas. Com relação às questões abertas o objetivo foi analisá-las procurando alcançar o sentido e não apenas o conteúdo do texto. Os resultados evidenciaram que a experiência de integração ensino-serviço analisada está proporcionando aprendizagens significativas sobre o funcionamento das redes de atenção especializada em saúde bucal e o desenvolvimento de competências para a resolução de problemas. A modificação de protocolos da atenção especializada em saúde bucal é uma experiência constante vivenciada pelos estagiários nos campos de estágio. Os aspectos da experiência com maior potencial inovador, político e pedagógico (os campos de gestão, as tutorias e a educação à distância) foram também os que apresentaram maior fragilidade.

The purpose of this study is to provide evidence of the validity, inter-rater reliability, and sensitivity of 36 clinically useful of Nursing Outcomes Classification (NOC) results for Home Care (HC) settings. The results of inter-rater reliability, criterion-related validity, and sensitivity evaluations of 36 NOC outcomes were compiled from a 10-site regional evaluation of the NOC. Findings of HC and all sites data were contrasted. More than 90% of the inter-rater reliability scores on the 36 NOC outcome label ratings were within one point, with a substantial number of absolute agreements. All but six of the criterion measures were significantly associated with the corresponding NOC outcomes, and most mean change scores were zero or positive. This was impressive evidence of the adequacy of these measures for reliable and valid use in practice.