标准化护理诊断分类体系构建的方法学文献研究  

Construction of standardized nursing diagnosis classification system on methodological literature research

作　　者：刘舒婷 陈连华 余艳[1] LIU Shuting;CHEN Lianhua;YU Yan(Zhujiang Hospital of Southern Medical University,Guangdong 510260 China)

机构地区：[1]南方医科大学珠江医院,广东510260 [2]汕头大学医学院

出　　处：《循证护理》2022年第13期1741-1747,共7页Chinese Evidence-Based Nursing

摘　　要：目的:研究国内外标准化护理诊断术语体系构建过程,探讨体系构建的理论框架、方法学及具体内容。方法:计算机检索中国知网(CNKI)、维普(VIP)、万方(WanFang Database)、PubMed、Web of Science、FMRS等数据库,对发表时间为2000年—2020年有关标准化护理诊断分类体系构建的文献,从作者、发表年份、国家、研究主题、主要研究方法、构建过程、理论框架和主要内容等8个方面进行汇总,并与国际官方组织正式发布的方法学指南进行比较分析。结果:共纳入19篇文献。纳入研究所构建的护理诊断分分类体系大多以国际护理实践分类(ICNP)为参考,以专科护理模式或护理理论为框架。结合美国护士协会(ANA)和国际护士协会(ICN)发布的子集发展指南,标准化护理诊断术语构建过程大致分为3个阶段:资料搜集阶段(文献回顾、临床资料收集、理论框架研究)、术语条目构建阶段(术语映射、按照ICNP护理诊断构成规则确定术语表述、德尔菲法)和术语验证阶段(目标人群的临床试用、各种形式的专家咨询、Fehring模型)。结论:国内外研究者持续关注标准化护理诊断术语的构建研究。但对不同国家来说,标准化护理诊断术语正式应用前需进行本土化调适。参考国际通用的标准化护理术语构建本土化护理术语体系,是当今信息化护理研究的重要领域。Objective:To study the construction process of standardized nursing diagnostic terminology systems at home and abroad,and to explore the theoretical framework,methodology and specific content of the system construction.Methods:The articles on the construction of a standardized nursing diagnostic classification system were retrieved from CNKI,VIP,WanFang Database,PubMed,Web of Science and FMRS databases,and the retrieval time was from 2000 to 2020.The research was summarized including author,publication year,country,research topic,main research methods,construction process,theoretical framework and main content,then compared with the methodology guidelines issued by international official organizations.Results:A total of 19 articles were included.Most of the nursing diagnostic classification systems included in the study took the International Classification of Nursing Practice(ICNP)as a reference and specialized nursing model or nursing theory as the framework.Based on the subset development guidelines issued by the American Nurses Association(ANA)and the International Association of Nurses(ICN),the process of building standardized nursing diagnostic terms can be roughly divided into three stages:data collection stage(literature review,clinical data collection,theoretical framework research),term entry construction stage(term mapping,determination of term expression according to ICNP nursing diagnosis constitution rules,Delphi method)and term verification stage(clinical trial of target population,various forms of expert consultation,Fehring model).Conclusion:Domestic and foreign researchers continue to pay attention to the construction of standardized nursing diagnosis terms.However,for different countries,standardization of nursing diagnostic terms needs to be localized before formal application.It is an important field of information nursing research to construct the localization nursing terminology system by referring to the international standardized nursing terminology.

关 键 词：标准化 护理术语 护理诊断 分类体系 方法学 

分 类 号：R47[医药卫生—护理学]