Applied Nursing Research 28 (2015) 92–98
Contents lists available at ScienceDirect
Applied Nursing Research
journal homepage: www.elsevier.com/locate/apnr
A retrospective study of nursing diagnoses, outcomes, and
interventions for patients with mental disorders
Paula Escalada-Hernández, PhD, MSc a,⁎, Paula Muñoz-Hermoso, BSc b, Eduardo González–Fraile, Msc, BSc c,
Borja Santos, Msc, BSc d, José Alonso González-Vargas, PMH CNS, BSc e, Isabel Feria-Raposo, PMH CNS, BSc f,
José Luis Girón-García, PMH CNS, BSc g, Manuel García-Manso, BSc h THE CUISAM GROUP 1
a
Public University of Navarre, Pamplona, Spain
Clínica Psiquiátrica Padre Menni, Pamplona, Spain
c
Instituto de Investigaciones Psiquiátricas, Bilbao, Spain
d
Universidad del País Vasco, Bilbao, Spain
e
Complejo Asistencial Hermanas Hospitalarias, Málaga, Spain
f
Benito Menni CASM, Sant Boi, Spain
g
Centro Neuropsiquiátrico Nuestra Sra. Del Carmen, Garrapinillos, Spain
h
Complejo Hospitalario San Luis, Palencia, Spain
b
a r t i c l e
i n f o
Article history:
Received 15 August 2013
Revised 24 March 2014
Accepted 28 May 2014
Keywords:
NANDA-I nursing diagnoses
NIC interventions
NOC outcomes
Psychiatric diagnoses
Mental disorders
a b s t r a c t
Aim: The aim of this study is to describe the most frequent NANDA-I nursing diagnoses, NOC outcomes, and
NIC interventions used in nursing care plans in relation to psychiatric diagnosis. Background: Although
numerous studies have described the most prevalent NANDA-I, NIC and NOC labels in association with
medical diagnosis in different specialties, only few connect these with psychiatric diagnoses. Methods: This
multicentric cross-sectional study was developed in Spain. Data were collected retrospectively from the
electronic records of 690 psychiatric or psychogeriatric patients in long and medium-term units and,
psychogeriatric day-care centres. Results: The most common nursing diagnoses, interventions and outcomes
were identified for patients with schizophrenia, organic mental disorders, mental retardation, affective
disorders, disorders of adult personality and behavior, mental and behavioural disorders due to psychoactive
substance use and neurotic, stress-related and somatoform disorders. Conclusion: Results suggest that
NANDA-I, NIC and NOC labels combined with psychiatric diagnosis offer a complete description of the
patients' actual condition.
© 2014 Elsevier Inc. All rights reserved.
⁎ Corresponding author at: Health Science Department, Public University of Navarre.,
Avenida de Barañain s/n. 31008, Pamplona, Navarre, Spain. Tel.: +34 948 14 06 11.
E-mail addresses: escalada.paula@gmail.com (P. Escalada-Hernández),
pmunoz@clinicapadremenni.org (P. Muñoz-Hermoso), egonzalezf@aita-menni.org
(E. González–Fraile), bsantos001@hotmail.com (B. Santos),
jagonzalez@hospitalariasmadrid.org (J.A. González-Vargas),
iferia@hospitalbenitomenni.org (I. Feria-Raposo), jlgiron@neuronscarmen.org
(J.L. Girón-García), mgarcia@sanluis.org (M. García-Manso).
1
The researchers who were part of the CUISAM Group were: Uxua Lazkanotegui
Matxiarena, Itxaso Marro Larrañaga, Janire Martínez Berrueta, Miren Arbelóa Álvarez,
Miriam García Sanabria, David Rodríguez Merchán, Cristina Flores Del Redal López and
Marta Alameda Blanco from Clínica Psiquiátrica Padre Menni (Pamplona, Spain);
Mertxe Olondriz Urrutia and Maite Dendarrieta Bardot from Centro Hospitalario Benito
Menni (Elizondo, Spain); Almudena Bueno García, Elena Muñoz Jiménez, Mª Esperanza
Pozo Cambeiro, Inmaculada Romero López, Juan Tomás Jiménez Pereña, Laura Cebreros
Cuberos, Laura Marín Rubio, Marina Rubio Guerrrero, Rocío Jiménez Sánchez, Sergio
Víctor Mata Reyes, Antonia Mª Ariza Nevado and Verónica Aguilar Pérez from Complejo
Asistencial Hermanas Hospitalarias (Málaga, Spain); Mª Carmen Vilchez Estévez,
Mónica Pastor Ramos and Alberto Carnero Treviño from Benito Menni CASM (Sant Boi,
Spain); Nuria García Sola, Natividad Izaguerri Mochales, Elena Martínez Araus, Eva Sanz
Báguena, Silvia Gabasa Galbez from Centro Neuropsiquiátrico Nuestra Sra. Del Carmen
(Zaragoza, Spain); Emilio Negro González from Complejo Hospitalario San Luis
(Palencia, Spain).
http://dx.doi.org/10.1016/j.apnr.2014.05.006
0897-1897/© 2014 Elsevier Inc. All rights reserved.
1. Background
Over the last decades, in the context of mental health care, important
reforms have taken place to promote the deinstitutionalization of
patients in many occidental countries (WHO & Wonca, 2008). In this
line, in Spain numerous changes have been undertaken to adopt a
community-based model of mental health care (Ministry of Health,
Equality Social Services, 2012). The Mental Health Strategy of the
Spanish National Health System 2009–2013 is the current guidance
document that, based on the evaluation of the present situation, outlines
the main lines of strategy and objectives for the improvement of mental
health care (Ministry of Health, Equality Social Services, 2012). This
document acknowledges the relevance of nurses' function and
promotes the incorporation of nurses who are certified as psychiatric–
mental health clinical nurse specialist as part of interdisciplinary teams
among all mental health care services. The mental health care services
include a variety of different types of health care settings for adult
patients: community mental health care centres, day care/psychosocial
rehabilitation centres, community residential/supported living services,
P. Escalada-Hernández et al. / Applied Nursing Research 28 (2015) 92–98
acute psychiatric units, medium and long-term psychiatric units and
psychogeriatric residential units (SIAP, 2009).
The nurses' role within the interdisciplinary teams can be
supported and enhanced with research on nursing care and practice
in the different mental health care services of the Spanish context. The
use of standardized languages to describe the elements of the nursing
process provides a systematic approach toward patient care and
allows describing nursing practice in a precise way (Johnson,
Moorhead, Bulechek, Maas, & Swanson, 2011; Nanda International,
2012; Thoroddsen, Ehnfors, & Ehrenberg, 2010). The nursing
diagnoses classification of the NANDA-International (NANDA-I;
Nanda International, 2012), the Nursing Outcomes Classification
(NOC; Moorhead, Johnson, Maas, & Swanson, 2013) and the Nursing
Interventions Classification (NIC; Bulechek, Butcher, Dochterman, &
Wagner, 2013) are three coded and standardized nomenclatures that
refer to the nursing process elements of diagnoses, interventions, and
outcomes. Each element in NANDA-I, NIC and NOC taxonomies
consists of a label name, a definition and a unique numeric code.
NANDA-I, NIC and NOC terminologies have widely been researched
and applied (Anderson, Keenan, & Jones, 2009; Johnson et al., 2011).
The three classifications together have the potential to represent
the domain of nursing in all settings (Johnson et al., 2011).
Thoroddsen et al. (2010) compared nursing diagnoses and nursing
interventions in four selected nursing specialties, including surgical,
medical, geriatric, and psychiatric areas. They concluded that
NANDA-I and NIC taxonomies illustrated the specific knowledge of
each specialty and were very useful in describing basic human needs
and nursing care in clinical practice. Nonetheless, they argued that
further research should be developed to identify specific nursing
diagnoses, nursing interventions and outcomes in different specialties. Two studies identified nursing phenomena (Frauenfelder,
Müller-Staub, Needham, & Van Achterberg, 2011) and nursing
interventions (Frauenfelder, Müller-Staub, Needham, & Achterberg,
2013) mentioned in journal articles on adult psychiatric inpatient
nursing care and compared them with the NANDA-I and NIC
terminologies respectively. Both studies concluded that these taxonomies described the majority, but not all, of concepts mentioned in the
literature. The authors suggested that additional development of the
taxonomies is needed to include all the relevant phenomena and
interventions for the nursing work in adult inpatient settings (Frauenfelder et al., 2011, 2013).
Numerous studies in different specialties have analyzed NANDA-I,
NIC and NOC elements in association with medical diagnoses or
diagnosis-related groups. It has been demonstrated that their
concurrent application offers complementary information about a
patient's actual condition that can be employed to predict patient
outcomes or use of resources (Güler, Eser, Khorshid, & Yücel, 2012;
van Beek, Goossen, & van der Kloot, 2005; Welton & Halloran, 2005).
In psychiatry and mental health care, only two studies examining the
prevalence of nursing diagnoses according to different psychiatric
diagnoses have been located. Ugalde Apalategui and Lluch Canut
(2011) described the most prevalent NANDA-I labels for nine
diagnosis-related groups and Vílchez Esteve, Atienza Rodríguez,
Delgado Almeda, González Jiménez, and Lorenzo Tojeiro (2007) for
five psychiatric diagnoses. Moreover, two additional papers examined
nursing diagnoses in patients with a specific psychiatric diagnosis,
such as schizophrenia (Chung, Chiang, Chou, Chu, & Chang, 2010;
Lluch Canut et al., 2009).
Beyond prevalence analyses, several research projects have
examined the relationship between the number of nursing diagnoses,
as a measure of nursing complexity, and patient outcomes. For
example, Moon (2011) found that the number of nursing diagnoses
was significantly related to the changes in selected NOC scores in ICU
patients and Sherb et al. (2013) obtained similar results in patients
with pneumonia or heart failure. In acute cardiac care, Meyer, Wang,
Li, Thomson, and O'Brien-Pallas (2009) demonstrated that the
93
number of nursing diagnoses increased the likelihood of suffering
medical consequences (e.g., medical errors with consequences,
urinary tract or wound infections) and reduce the extent to which
physical and mental health improved at discharge (measured by
difference scores between admission and discharge in the SF-12
Health Status Survey). To the author's knowledge, this aspect has not
been explored in psychiatric patients.
Examining nursing practice by analyzing NANDA-I, NIC and NOC
labels mentioned in nursing records in mental health nursing practice
may contribute to develop knowledge within the specialty. The aim of
this study is to describe the most frequent nursing diagnoses,
outcomes, and interventions used in nursing care plans for psychiatric
and psychogeriatric patients in medium and long-term care facilities
in relation to psychiatric diagnosis. The research questions were:
(a) Which nursing diagnoses, outcomes and interventions are used in
nursing care plans according to psychiatric diagnosis? (b) Is there any
relationship between the variables number of nursing diagnoses,
psychiatric diagnosis, age or gender and the degree of severity of
problems associated with mental illness?
2. Research methods
2.1. Data collection procedures and sample
This multicentric cross-sectional study was performed in 5
psychiatric clinics in different regions of Spain. These centres belong
to the Congregation of Sisters Hospitallers of the Sacred Heart of Jesus.
The electronic medical record software used in these centres
integrates NANDA-I, NIC and NOC taxonomies and nurses have used
them routinely to develop healthcare plans for some years now.
Data were collected retrospectively from the nursing care plans
included in the electronic patient records. No sampling strategy was
used as the whole study population was included in the study. The
study population consisted of all those records of patients fulfilling the
inclusion/exclusion criteria who were hospitalized between June
2010 and July 2011. Subjects eligible for inclusion were adult (aged
over 18) psychiatric and psychogeriatric patients, who had a nursing
care plan with NANDA-I, NIC and NOC labels and stayed at any of the
healthcare facilities under study. These were long-term psychiatric
units, medium-term psychiatric units, long-term psychogeriatric units
and psychogeriatric day-care centres. Long-term units are residential
services and patients may stay there indefinitely. Patients usually stay
in medium-term units between 1 and 6 months. As exclusion criteria,
due to ethical considerations, all patients in a terminal condition were
not considered eligible. Records of patients who were readmitted
after discharge during the data collection period were excluded.
This research project was approved by the Ethical and Scientific
Research Committee of Navarra. To ensure anonymity each electronic
patient record was assigned an ID-number. Access to medical electronic
records was granted by participating centres. In addition, although not
necessary, written informed consent from all participants or their legal
guardians was obtained to add ethical value to the study. In order to
facilitate a systematic data collection, all members of the research team
used a data collection form and received a training session.
2.2. Variables
The content of the data collection form consisted of 4 data sets
relating to socio-demographic details, medical information, NANDA-I,
NIC and NOC codes and the Health of the Nation Outcome Scale
(HoNOS), respectively. The socio-demographic details collected were
age, gender, marital status, socio-economic status, education and
employment situation. The medical information included primary
psychiatric diagnosis according to ICD-10 classification (secondary
diagnoses, if present, were not considered), clinical area (psychiatry
or psychogeriatry) and type of healthcare setting (i.e. day-care centre,
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P. Escalada-Hernández et al. / Applied Nursing Research 28 (2015) 92–98
Table 1
Socio-demographic characteristics of the sample.
Data
Age groups
19–30 year
31–50 years
51–65 years
66–85 years
≥85 years
Gender
Women
Men
Marital status
Single
Married
Divorced/Separated
Widower
Unkown
Socio-economic status
Low
Low-medium
Medium
High-medium
High
Unkown
Education
Illiterate
Primary school level
Secondary school level
University level
Unknown
Employment situation
Employed
Unemployed
In pension
n
%
15
101
153
326
96
2.17
14.62
22.14
47.18
13.89
432
257
62.70
37.30
381
99
60
130
21
55.14
14.33
8.68
18.81
3.04
179
173
156
63
16
104
25.90
25.04
22.57
9.12
2.32
15.05
74
332
100
51
134
10.71
48.05
14.47
7.38
19.39
6
75
602
0.88
10.98
88.14
medium or long-term unit). In relation to NANDA-I, NIC and NOC
taxonomies, the codes of nursing diagnoses, outcomes and interventions documented in nursing care plans were recorded. In addition,
clinical problems and social functioning of patients were assessed by
HoNOS in its Spanish version (Uriarte et al., 1999). HoNOS is an
instrument with 12 items designed to measure the whole range of
physical, personal and social problems associated with mental illness.
The score in each item ranges from 0 (i.e. without problems) to 4
(serious or very serious problems). Thus, the total HoNOS score may
range from 0 to 48.
This scale has a broad clinical and a social coverage; it is used as a
clinical outcome measure and is suitable for routine application by
nurses (Pirkis et al., 2005; Wing et al., 1998). Different studies of the
psychometric properties of the scale showed an adequate internal
consistence with Cronbach's alpha ranging from 0.59 to 0.76,
indicating that HoNOS provides a clear overview of severity of
symptoms (Pirkis et al., 2005). Studies that analyzed the test–retest
reliability of the scale have reported fair to moderate scores and those
that examined its inter-rater reliability concluded that overall
agreement between raters was moderate to good for the HoNOS
total score (Pirkis et al., 2005).
2.3. Data analyses
Data were analyzed with MS Excel and STATA V.12.1 software
(StataCorp LP). To determine the most frequent NANDA-I, NIC and
NOC labels in relation to psychiatric diagnosis, the sample was divided
into groups according psychiatric diagnosis categories. Descriptive
analyses were performed using absolute frequency distribution and
percentage. For the second research question, additional statistical
analyses were executed on the data from the total sample. The
Pearson correlation coefficient was calculated to explore the relationship between the number of nursing diagnoses and the total score in
HoNOS. A multiple regression model was performed where total
HoNOS score was the independent variable and the dependent
variables were psychiatric diagnosis, number of nursing diagnoses,
age and gender.
3. Results
Socio-demographic information of the study sample is presented
in Table 1. The final sample included the records of 690 patients. From
them, 434 (62.90%) were female and 256 (37.10%) were male. The
average age was 67.9 ± 16.8 years (range 19–101). More than 50% of
subjects were married, around 70% had a socio-economic status
between low and medium, the majority (88%) were in pension and
approximately 50% had primary school level education. The number
of participants admitted in long-term psychiatric units was 219
(31.74%), 54 (7.83%) in medium-term psychiatric units, 351 (50.87%)
in long-term psychogeriatric units and, 66 (9.56%) in psychogeriatric
day-care centres.
Psychiatric diagnoses were classified according to the main
categories of ICD-10, obtaining the following groups: group 1:
schizophrenia, schizotypal and delusional disorders (n = 362;
52.46%); group 2: organic mental disorders (n = 182; 26.38%);
group 3: mental retardation (n = 37; 5.36%); group 4: bipolar
affective disorders (n = 33; 4.78%); group 5: depressive and other
affective disorders (n = 22; 3.19%); group 6: disorders of adult
personality and behaviour (n = 21; 3.04%); group 7: mental and
behavioural disorders due to psychoactive substance use (n = 17;
2.46%); group 8: neurotic, stress-related and somatoform disorders
(n = 14; 2.03%); other disorders (n = 2; 0.30%).
Below, the main results will be presented in order of the
research questions.
3.1. (a) Which nursing diagnoses, outcomes and interventions are used
in nursing care plans according to psychiatric diagnosis?
In all, 3681 nursing diagnoses, 4685 nursing outcomes and 13396
nursing interventions were recorded. The average number of nursing
diagnoses per patient was 5.3. Similarly, the average numbers of
nursing outcomes and nursing interventions per patient were 6.8 and
19.4 respectively.
Nursing diagnoses, outcomes and interventions were analyzed
within each psychiatric diagnosis group. The most frequent NANDA-I,
NOC and NIC labels for each group are illustrated in Tables 2A and 2B.
The most prevalent labels are mainly related to psychosocial and
self-care deficit aspects. Certain patterns or profiles were observed
within each psychiatric diagnosis group. In group 1 (schizophrenia,
schizotypal and delusional disorders), NANDA-I, NIC and NOC terms
illustrated the usual needs faced by patients with schizophrenia such
as disturbance of thought processes and social, communication,
anxiety and treatment compliance problems. Nursing diagnoses,
outcomes and interventions in relation to self-care deficit were
more predominant in groups 2 (organic mental disorders) and 3
(mental retardation). Within group 4 (bipolar affective disorders),
NANDA-I, NIC and NOC labels are mainly related to self-care deficits
and, symptom and side-effects management (i.e. disturbance of
thought processes and constipation) and treatment compliance.
NANDA-I, NIC and NOC labels in groups 5 (depressive and other
affective disorders) and 8 (neurotic, stress-related and somatoform
disorders) showed a special focus on anxiety problems. Groups 6
(disorders of adult personality and behaviour) and 7 (mental and
behavioural disorders due to psychoactive substance use) had a
majority of nursing diagnoses, outcomes and interventions related to
social interaction and self-care needs. Moreover, some labels in group
7 (mental and behavioural disorders due to psychoactive substance
use) referred to side-effects such as constipation.
P. Escalada-Hernández et al. / Applied Nursing Research 28 (2015) 92–98
95
Table 2A
Most frequent NNN labels by psychiatric diagnosis group.
Group 1: schizophrenia, schizotypal
and delusional disorders (n = 362)
Group 2: organic mental
disorders (n = 182)
Group 3: mental
retardation (n = 37)
Group 4: bipolar affective
disorders (n = 33)
NANDA
108 self-care deficit: bathing
130 disturbed thought
processes
52 impaired social interaction
n
%
NANDA
207 57,18 109 self-care deficit: dressing
174 48,07 108 self-care deficit: bathing
n
%
NANDA
122 67,03 108 self-care deficit: bathing
116 63,74 109 self-care deficit: dressing
n
%
NANDA
17 45,95 108 self-care deficit: bathing
15 40,54 11 constipation
n
%
16 48,48
13 39,39
139 38,40 102 self-care deficit: feeding
89
48,90 102 self-care deficit: feeding
8
12 36,36
51 impaired verbal
communication
78 ineffective self health
management
108 29,83 131 impaired memory
71
39,01 11 constipation
7
108 29,83 51 impaired verbal
communication
59
32,42 97 deficient diversional
activity
6
n
%
NOC
168 46,41 300 self-care: activities of daily
living (ADL)
153 42,27 305 self-care: hygiene
n
%
NOC
150 82,42 300 self-care: activities of
daily living (ADL)
105 57,69 305 self-care: hygiene
133 36,74 1101 tissue integrity:
skin and mucous membranes
126 34,81 302 self-care: dressing
80
NOC
305 self-care: hygiene
21,62 130 disturbed thought
processes
18,92 78 ineffective self health
management
16,22 97 deficient diversional
activity
12 36,36
11 33,33
n
%
NOC
19 51,35 1612 weight control
n
9
%
27,27
8
24,24
43,96 302 self-care: dressing
15 40,54 300 self-care: activities of
daily living (ADL)
10 27,03 305 self-care: hygiene
8
24,24
77
42,31 1604 leisure participation
8
8
24,24
1502 social interaction skills 126 34,81 902 cognitive orientation
57
31,32 501 bowel elimination
7
8
24,24
NIC
1801 self-care assistance:
bathing/hygiene
5606 teaching: Individual
n
%
NIC
156 85,71 5606 teaching: individual
n
%
NIC
24 64,86 200 exercise promotion
n
%
23 69,70
137 75,27 1801 self-care assistance:
bathing/hygiene
128 70,33 5820 anxiety reduction
120 65,93 200 exercise promotion
19 51,35 5820 anxiety reduction
20 60,61
5820 anxiety reduction
4820 reality orientation
n
%
NIC
226 62,43 6480 environmental
management
212 58,56 1801 self-care assistance:
bathing/hygiene
194 53,59 5606 teaching: Individual
175 48,34 6490 fall prevention
17 51,52
16 48,48
5100 socialization
enhancement
2380 medication
management
4920 active listening
153 42,27 1802 self-care assistance:
dressing/grooming
152 41,99 6486 environmental
management: safety
147 40,61 1800 self-care assistance
119 65,38 1800 self-care assistance
16 43,24 4820 reality orientation
15 40,54 2300 medication
administration
13 35,14 5606 teaching: individual
12 32,43 1801 self-care assistance:
bathing/hygiene
12 32,43 4920 active listening
14 42,42
4480 self-responsibility
facilitation
5230 coping enhancement
146 40,33 6460 dementia management
115 63,19 6480 environmental
management
107 58,79 1802 self-care assistance:
dressing/grooming
102 56,04 1670 hair care
13 39,39
145 40,06 4820 reality orientation
97
53,30 1680 nail care
92
50,55 1660 foot care
12 32,43 2380 medication
management
11 29,73 4480 self-responsibility
facilitation
11 29,73 5100 socialization
enhancement
1403 distorted thought
self-control
300 self-care: activities of
daily living (ADL)
901 cognitive orientation
4362 behavior modification: 133 36,74 1803 self-care assistance:
social skills
feeding
3.2. (b) Is there any relationship between the variables number of
nursing diagnoses, psychiatric diagnosis, age or gender and the degree of
severity of problems associated with mental illness?
Data from the total sample were used to examine potential
relationships between number of nursing diagnoses, psychiatric
diagnosis, age or gender and the degree of severity of problems
associated with mental illness (as reflected by HoNOS total score). The
mean of the HoNOS score in the total sample was 13.24 ± 5.97. The
result of the Pearson correlation test (r = 0.22) was statistically
significant (p b 0.05) and indicated a moderate positive linear
relationship between HoNOS total score and the number of nursing
diagnoses. Several stepwise regression models were devised to
determine the explanatory factors for the HoNOS total score. Initially,
number of nursing diagnoses, psychiatric diagnoses, age and gender
were included as independent variables the HoNOS total score as
dependent variable. The final multiple regression model (Table 3)
revealed that only gender and number of nursing diagnoses had a
significant influence on the HoNOS total score. The gender coefficient
(− 1.35 ± 0.45) represents that adjusting for the nursing diagnoses,
women would have had a HoNOS total score one point less than men.
According to the coefficient of the number of nursing diagnoses
(0.44 ± 0.07), an increment of five diagnoses adjusting for gender
represents a 2-point increment in the HoNOS total score.
21,62 1403 distorted thought
self-control
18,92 1608 symptom control
15 45,45
14 42,42
13 39,39
13 39,39
4. Discussion
The findings of this study describe the most frequent NANDA-I, NIC
and NOC labels for groups of patients with different psychiatric
diagnoses in medium and long-term units. Overall, some common
aspects among all groups were found. NANDA-I, NIC and NOC labels in
all groups reflected nursing care related to patients' psychosocial
needs, self-care deficits and management of the therapeutic regimen.
The domain of psychiatric nursing specialty, although not exclusively,
focuses on these aspects (Frauenfelder et al., 2011; Sales Orts, 2005;
Ugalde Apalategui & Lluch Canut, 2011). Nursing care related to
patients' psychosocial needs were described by nursing diagnoses
such as disturbed thought processes, impaired social interaction,
impaired verbal communication, deficient diversional activity or anxiety;
outcomes such as distorted thought self-control, social interaction skills,
cognitive orientation, leisure participation or anxiety self-control; and
interventions such as active listening, anxiety reduction, socialization
enhancement, reality orientation, exercise promotion or coping enhancement. In relation to self-care needs, for instance, several nursing
diagnoses of self-care deficit (i.e. bathing, dressing, and feeding) and its
related outcomes and interventions can be observed. Furthermore,
NANDA-I, NIC and NOC labels such as ineffective self health
management, medication management or medication administration
illustrated how attention to the management of the therapeutic
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P. Escalada-Hernández et al. / Applied Nursing Research 28 (2015) 92–98
Table 2B
Most frequent NNN labels by psychiatric diagnosis group.
Group 5: depressive and other
affective disorders (n = 22)
NANDA
108 self-care deficit:
bathing
130 disturbed thought
processes
146 anxiety
109 self-care deficit:
dressing
16 impaired urinary
elimination
NOC
305 self-care: hygiene
Group 6: disorders of adult
personality and behavior (n = 21)
Group 7: mental and behavioural
disorders due to psychoactive
substance use (n = 17)
n
%
NANDA
12 54,55 108 self-care deficit: bathing
n
%
NANDA
11 52,38 108 self-care deficit: bathing
9
40,91 97 deficient diversional activity
7
8
7
36,36 52 impaired social interaction
31,82 109 self-care deficit: dressing
6
6
33,33 51 impaired verbal
communication
28,57 52 impaired social interaction 7
28,57 11 constipation
5
7
31,82 78 ineffective self health
management
5
23,81 109 self-care deficit: dressing
4
n
8
n
%
NOC
12 54,55 1604 leisure participation
300 self-care: activities of 8
daily living (ADL)
1403 distorted thought
8
self-control
1502 social interaction skills 7
41,18 146 anxiety
29,41 109 self-care deficit:
dressing
23,53 130 disturbed thought
processes
4
28,57
n
%
NOC
11 64,71 1502 social interaction skills
n
9
%
64,29
10 58,82 305 self-care: hygiene
5
35,71
5
35,71
5
35,71
5
35,71
36,36 305 self-care: hygiene
5
23,81 1604 leisure participation
6
31,82 1101 tissue integrity: skin and
mucous membranes
31,82 300 self-care: activities of daily
living (ADL)
5
23,81 501 bowel elimination
5
35,29 1403 distorted thought
self-control
29,41 1503 social involvement
4
19,05 901 cognitive orientation
5
29,41 1402 anxiety self-control
n
%
NIC
20 90,91 200 exercise promotion
1801 self-care assistance:
bathing/hygiene
5606 teaching: individual
16 72,73 5230 coping enhancement
n
%
NIC
15 71,43 1801 self-care assistance:
bathing/hygiene
12 57,14 200 exercise promotion
12 54,55 4310 activity therapy
11 52,38 5820 anxiety reduction
5230 coping
enhancement
4820 reality orientation
12 54,55 5100 socialization enhancement
2300 medication
administration
4920 active listening
11 50,00 6490 fall prevention
11 52,38 6486 environmental
management: safety
11 52,38 5100 socialization
enhancement
11 52,38 4820 reality orientation
11 50,00 5820 anxiety reduction
n
%
NIC
15 88,24 5820 anxiety reduction
n
%
12 85,71
15 88,24 4362 behavior modification:
social skills
10 58,82 5100 socialization
enhancement
9
52,94 5230 coping enhancement
12 85,71
9
52,94 200 exercise promotion
9
64,29
9
52,94 1801 self-care assistance:
bathing/hygiene
47,06 4310 activity therapy
7
50,00
6
42,86
6
42,86
6
42,86
6
42,86
10 45,45 6486 environmental management: 10 47,62 6490 fall prevention
safety
10 45,45 4920 active listening
10 47,62 5606 teaching: Individual
8
10 45,45 2380 medication management
9
7
41,18 4640 anger control
assistance
41,18 4920 active listening
9
8
6
35,29 4820 reality orientation
40,91 4420 patient contracting
42,86 2300 medication
administration
38,10 1800 self-care assistance
regimen also appeared in the nursing care plans. This supports the
conclusions of Thoroddsen et al. (2010), who demonstrated that
standardized nursing languages have the potential of representing
specific knowledge within nursing specialties, including mental
health nursing.
Within each psychiatric diagnosis group specific patterns and
features can be observed, demonstrating that psychiatric diagnosis
and NANDA-I, NIC and NOC labels were related. Findings in group 1
(i.e. patients with schizophrenia) are consistent with the literature.
Three of the most prevalent nursing diagnoses in this group: disturbed
thought processes, ineffective self health management and self-care
deficit: bathing were also found very frequent in other studies on
Table 3
Final multiple regression model.
Dependent variable: HoNOS score
Significance
2
R = 0.566
0.000
Model
Stand coefficient Significance CI 95%
(independent variables) (beta)
Low
−1.353
0.439
0.003
0.000
High
−2.247 −0.459
0.292
0.586
35,71
35,71
28,57
6
NIC
5820 anxiety reduction
%
50,00
5
4
36,36 1209 motivation
7
Gender
Number of diagnoses
n
%
NANDA
n
13 76,47 52 impaired social
7
interaction
8
47,06 108 self-care deficit: bathing 5
%
NOC
38,10 300 self-care: activities of
daily living (ADL)
28,57 305 self-care: hygiene
4 sleep
2380 medication
management
6486 environmental
management: Safety
1850 sleep enhancement
Group 8: neurotic, stress-related and
somatoform disorders (n = 14)
7
10 71,43
10 71,43
patients with schizophrenia and schizotypal and delusional disorders
(Chung et al., 2010; Lluch Canut et al., 2009; Ugalde Apalategui &
Lluch Canut, 2011; Vílchez Esteve et al., 2007) For the rest of the
psychiatric diagnosis groups, comparisons between this study and the
other two existing studies are difficult as they classified psychiatric
diagnoses in a different way, using diagnosis-related groups (Ugalde
Apalategui & Lluch Canut, 2011) or other diagnostic categories such as
mania, depression, dual disorders or adaptative disorders (Vílchez
Esteve et al., 2007). Clinical manifestations and diagnostic criteria
differ among classifications, and therefore, patients' characteristics
and needs in each group will be different in some degree.
The statistical analyses performed showed that HoNOS total score
was related with the variable number of nursing diagnoses and not
with the variable psychiatric diagnosis. Based on these results, it could
be argued that the degree of severity of patients' problems has an
impact on nursing care requirements. This relationship between
patients' level of physical and mental health and number of nursing
diagnoses has been demonstrated in previous research (Meyer et al.,
2009). This result supports the use of number of nursing diagnoses as
a measure of nursing complexity that could be used as predictors of
patient outcomes (Meyer et al., 2009; Moon, 2011; Sherb et al., 2013).
Nursing diagnoses may provide relevant data that could be applied to
inform predictions or management decisions about nurse staffing or
P. Escalada-Hernández et al. / Applied Nursing Research 28 (2015) 92–98
resource utilisation (Hoi, Ismail, Ong, & Kang, 2010; Meyer et al.,
2009; Morales-Asencio et al., 2009).
The results of this study offer a broad picture of the nursing care to
psychiatric and psychogeriatric patients in medium and long-term
care settings, as they included the three main aspects of the nursing
process (i.e. nursing diagnoses, interventions and outcomes). In
addition, information about the specific nursing care needs in relation
to a determined psychiatric diagnosis has been obtained. Thus, the
present study contributes, to some extent, to complete the existing
evidence. As explained above, only a small number of studies
examining nursing diagnoses in association to specific psychiatric
diagnoses were located and research on NANDA-I, NIC or NOC
taxonomies in psychiatry and mental health has been mainly
developed in acute care or community settings and only included
either nursing diagnoses or nursing interventions (Escalada Hernández,
Muñoz Hermoso, & Marro Larrañaga, 2013). Additional research is
needed to complete and validate the findings of this study. The
evidence obtained from this kind of studies will contribute to
reinforce the mental health nurses' role within multidisciplinary
teams as can be applied for evidence-based practice, planning
continuing education programs, the improvement of the quality
of care, the development of standardized care plans and to
provide evidence of the value of mental health nurses' work to
stakeholders (Jones, Lunney, Keenan, & Moorhead, 2010; Nanda
International, 2012).
The present study has some potential limitations. Data were
obtained retrospectively from electronic patient records and not from
direct observation of nurses' work. Therefore, the study results
illustrate documented care and not delivered care. The use of
standardized language has been shown to improve the amount and
quality of data documented (Saranto et al., 2013). However, other
studies have found that nurses tend to communicate and register less
activities than those they actually perform (De Marinis et al., 2010;
Jefferies, Johnson, & Griffiths, 2010). On the other hand, as the sample
was divided into groups according to psychiatric diagnosis, the total
number of patients in the groups related to less prevalent pathologies
is very low. Therefore, findings from these groups should be examined
with caution and future studies focusing on those psychiatric
disorders are needed to complete these results.
5. Conclusions
The results of this study showed that the most common nursing
diagnoses, interventions and outcomes documented in nursing care
plans for psychiatric and psychogeriatric patients admitted in
medium and long-term care units and psychogeriatric day-care
centres are mainly related to psychosocial, self-care deficits and
management of the therapeutic regiment. The most frequent
NANDA-I, NIC and NOC labels for each psychiatric diagnosis have
been identified and specific patterns and differences between groups
can be observed. Furthermore, the degree of severity of problems
associated with mental illness, measured by HoNOS, has been shown
to be related to the number of nursing diagnoses recorded in the care
plan and not to the patient's psychiatric diagnosis. From the findings
presented here, it could be concluded that NANDA-I, NIC and NOC
labels combined with psychiatric diagnoses offer a comprehensive
description of psychiatric and psychogeriatric patients' actual condition, their problems and needs.
Acknowledgments
We are grateful to the Fundación Mª Josefa Recio and the Clínica
Psiquiátrica Padre Menni who funded this project and supported
its development.
Borja Santos was supported by the Department of Education,
Universities and Research of the Government of the Basque Country
97
(DEUI) through the Training and Development Programs for Research
Staff (BFI-2011-212).
The authors would like to thank Sr Patricia Grady ODN for the
valuable review of the manuscript for English usage.
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