Assessment of nursing care using indicators generated by software1

OBJECTIVE: to analyze the efficacy of the Nursing Process in an Intensive Care Unit using indicators generated by software. METHOD: cross-sectional study using data collected for four months. RNs and students daily registered patients, took history (at admission), performed physical assessments, and established nursing diagnoses, nursing plans/prescriptions, and assessed care delivered to 17 patients using software. Indicators concerning the incidence and prevalence of nursing diagnoses, rate of effectiveness, risk diagnoses, and rate of effective prevention of complications were computed. RESULTS: the Risk for imbalanced body temperature was the most frequent diagnosis (23.53%), while the least frequent was Risk for constipation (0%). The Risk for Impaired skin integrity was prevalent in 100% of the patients, while Risk for acute confusion was the least prevalent (11.76%). Risk for constipation and Risk for impaired skin integrity obtained a rate of risk diagnostic effectiveness of 100%. The rate of effective prevention of acute confusion and falls was 100%. CONCLUSION: the efficacy of the Nursing Process using indicators was analyzed because these indicators reveal how nurses have identified patients' risks and conditions, and planned care in a systematized manner.


Introduction
A search for improved quality of care provided to patients has gained prominence in the world context in recent decades and nursing, as well as in other professions, has faced the need to improve work processes (1) .
The Systematization of Nursing Care (SNC) is indicated as a method capable of improving the quality of nursing care because it provides scientific support, security and direction to the performance of the nursing staff's activities (2)(3) . One of the tools that should be used in the implementation of SNC is the Nursing Process (NP), a scientific method nurses can use to apply technical-scientific and practical knowledge into clinical practice (4) . Its effective application leads to improved healthcare quality, encourages the construction of evidence-based theoretical and scientific knowledge, helps in the development of protocols, grounds teaching and clinical rationales, and the management of costs and planning of resource allocation to quality nursing services (5)(6) .
The increased volume of data accruing from recording NP stages favors the development and broader use of computer systems, which enables the pursuit of actions to be directed based on organized data that becomes available to professionals through nursing information systems (7) . SIPETi was experimentally applied in an ICU to establish its applicability. Data, however, were not sufficient to generate all indicators concerning nursing care delivery proposed in the system's assessment module.
Given the need to provide tools to nurses seeking quality in their nursing care by using indicators that address the NP, it is necessary for nurses to have the standardized and computerized nursing data that are essential to assessing the effectiveness of care and verification of contributions to outcomes achieved by patients.
Additionally, it is also necessary that studies address the relationship among Nursing Diagnoses (NDx), interventions, and outcomes, showing the contributions made by NP and its importance to the quality of systematizing care (8) .
Since SIPETi was developed to generate indicators capable of establishing this relationship, the system's assessment module, from which data can be retrieved, needs to be validated for the system to be used with this purpose.
This study's general objective was to analyze NP efficacy using indicators generated by software in an adult ICU located in Belo Horizonte, MG, Brazil. The specific objectives included identifying the incidence and prevalence of nursing diagnoses in a group of inpatients in an ICU in Belo Horizonte and identify the rate of risk diagnostic effectiveness and effectiveness rate in the prevention of complications among inpatients included in the study. create themselves in a computerized system. The use of software with daily input was initiated for some of the patients during its implementation, as a test. These two beds were chosen because they are separated from the remaining beds within the ICU's physical structure and also due to the need to establish a number of patients that would enable data collection to be performed by the professionals who volunteered for the task together with the researchers, all specifically trained to collect data using the computerized system.

Method
In the event a patient included in the study was transferred to a bed not selected for this study, his/her monitoring within the ICU would be performed up to discharge, removal to another unit, or death. Patients were excluded if admitted to one of the selected beds but discharged, transferred to another unit, or if they died before the first data collection using the software. RNs and students through Batista's concordance test.
Three RNs and three students were considered able to perform data collection, as they obtained a level of agreement greater than 80% (9) .
The RNs and students properly trained took turns daily to register patients and history-taking (at admission), physical assessment, establishment of Nursing Diagnoses (NDx), nursing planning/ prescription, and assessment of care provided to the patients admitted to the first two beds in the ICU up to discharge, transfer, or death. After information was included in SIPETi, data necessary for the computation of nursing indicators were retrieved.
NDx concerning Risk for constipation, Risk for acute confusion, Risk for imbalance in body temperature, Risk for impaired skin integrity, and Risk for falls and the respective actions prescribed during the entire hospitalization, within the studied period, were selected for the calculation of indicators. These NDx were chosen because studies show these are among the most frequent NDx presented by critical patients admitted in ICUs (10)(11) . Additionally, falls and pressure ulcers have been mentioned as the main events to be prevented for the safety of patients (12) used to compose the SIPETi database, as well as to be used as indicators of the quality of nursing care,.
The following indicators, proposed by the Order of Nurses of Portugal (13) , which belong to the set of essential nursing data, were selected:

Incidence:
Number of new cases of a given diagnosis in a given period x 100 Existing population in the same period A case concerning a given diagnosis was considered to be new when identified after the patient's first assessment, that is, after admission. Note that a diagnosis under which a patient is admitted is not considered to be a new case, even if the diagnosis is resolved and identified again afterwards. Prevalence: Number of cases of a given diagnosis in a given period x 100 Existing population in the same period In this study, a case of a given diagnosis was considered when it was identified at some point during the patient's hospitalization.
Rate of risk diagnosis effectiveness: Number of cases, which developed into a given real condition with risk previously documented in a given period x 100 Number of cases in which the patient developed a real condition in the same period The number of cases of patients who developed a real condition was identified based on real nursing diagnoses or adverse events, as described in Figure   1. A case in which risk was previously documented was considered one in which a risk diagnosis was identified on the day before the occurrence of the real condition.
Rate of effective prevention of complications: Number of cases at risk of developing a given condition, but which did not develop

Results
A total of 142 patients were admitted to the ICU during data collection. Seventeen (12%) patients occupied the beds selected for this study and all these composed the study's sample. Ten of these patients were male and represented 59% of the total. Age ranged from 26 to 91 years old, with an average age of 68 years old and a median of 76 years old. All the patients were hospitalized using health insurance plans. Duration of hospitalization ranged from three to 42 days, with 13 days on average and a median of nine days.

The NDx Risk for imbalanced body temperature and
Risk for impaired skin integrity were the most incident: 23.53% and 11.76%, respectively. The NDx Risk for acute confusion and Risk for falls had an incidence of 5.88%, while Risk for constipation had an incidence of 0%.
In regard to prevalence, Risk for impaired skin integrity was prevalent in 17 (100%) patients, followed    Another study also identified this NDx in most patients hospitalized in an adult ICU (15) .
The NDx Risk for falls had low incidence because it was identified in only one patient during hospitalization.
Its prevalence, however, was high. This means that Risk for falls was identified in most patients at the time of admission. This finding is due to the fact that the risk factors of this specific ND are common among patients admitted in the studied ICU, such as being older than 65 years old, acute disease, and impaired physical mobility.
The NDx Risk for acute confusion had low incidence and prevalence. These indexes can be associated with the fact that some of the factors related to acute confusion include being older than 60 years old and having dementia, while the latter is often confounded with acute confusion itself, leading to errors of omitting others, which are common in severely ill patients (14) .
One study shows that risk factors such as immobility and mechanical factors are among the risks most frequently found concerning Risk for impaired skin integrity among patients hospitalized in ICUs (16) . The high prevalence of the NDx Risk for impaired skin integrity corroborates data found in another study, which also predicted this ND for 100% of the women hospitalized in an ICU (17) .
Three patients were identified with the ND Acute to this assertion is the fact that this ND presented an

Rate of effectiveness in the prevention of complications (%)
Risk for imbalanced body temperature 15   worth noting, however, that this ND was one of the most prevalent, with 88.23%. One study also showed low occurrence of falls in the ICU, corresponding to 0.05% (18) .
In addition to a concern regarding the complications this adverse event may cause, falls are less common in  (19) . Braden scale, was moderate on the day in which three ulcers were verified and high on the remaining days. It is, however, necessary that further studies addressing larger samples and other NDx be conducted in order to enable a more comprehensive assessment of NP efficacy.

Conclusion
Given the undeniable need to provide tools to nurses and establish strategies to measure and improve the quality of nursing care, it is important that essential data concerning nursing be standardized and computerized to assess the effectiveness of care and how nursing care contributed to the outcomes achieved by the patients.
In this sense, it is essential to establish indicators that address NP.
It is not possible to infer which given nursing intervention was decisive in keeping a condition from developing, though they certainly contributed. Further research focusing on the efficacy of actions is needed to prevent the occurrence of complications among patients hospitalized in ICUs and, for that, it is necessary that nurses establish nursing prescriptions for each diagnosis identified among the patients under their care.