從NANDA-I到ICNP之系統化輔助對應方法 – 以 NANDA-I 領域 2、領域 3之診斷為例

A systematic approach to support mapping between NANDA-I and ICNP – Focusing on the diagnoses in the domain 2 and 3 of NANDA-I

楊沛馨(Pei-Hsin Yang)

指導教授 ： 劉建財

臺北醫學大學/醫學科技學院/醫學資訊研究所/碩士(2012年)

摘要

背景：在資訊交換與分析的需求下，標準化護理詞彙為必然之發展物，且因應臨床各種不同需求，相關之標準詞彙亦呈現多方發展。其中 NANDA-I 護理診斷發展最早，亦為台灣護理人員熟悉，NANDA-I 以特定名稱來描述診斷概念，為一有效率之紀錄方法；而以國際發展為目的之 ICNP，因其特殊的詞彙使用設計，使能更結構化的分類儲存與分析護理資料，而這樣的結構設計亦為其臨床應用帶來挑戰。台灣於 1999 年加入 ICNP 計畫，之後亦陸續進行翻譯與適用性研究，但在 Version 1 發佈後相關研究便逐漸減少，而 Version 1 卻是 ICNP 在架構設計上有革命性改變的開始。

目的：NANDA-I 有效率的紀錄方法以及台灣臨床人員的高度熟悉，與 ICNP 的結構化分類儲存方法，若能將兩者對應，連結兩者優點，在應用上以 NANDA-I 方式紀錄而能對應、轉換成 ICNP 分類儲存，將能促進臨床護理實作記錄資料之應用。為協助對應過程進行，本研究目的為發展一個系統化對應方法，協助推薦自 NANDA-I 對應至 ICNP 之高相關性詞彙，期待提升相關對應過程的效率。

方法：將 NANDA-I（2012 ~ 2014）對應至 ICNP（2011 Release），以英文版本為主，並選擇 NANDA-I 領域 2、領域 3 中實證等級（Level Of Evidence, L.O.E.）達到 2.1 以上，為 NANDA-I 中較穩定之 18 個診斷為例，以一連串預設之對應規則，對應至 ICNP 呈現「診斷」時的必需軸向：焦點（Focus）與判斷（Judgment），以相關性強度等級方式將結果以級別分類，並依等級順位排序得到推薦詞彙。

結果：在推薦之 ICNP 詞彙中，給予護理專家評估，有關對應程度包括 6 個「完全對應」、7 個「部份對應」以及 5 個「無法對應」；而在推薦對應正確率評估中，則包括 9 個「正確推薦」、5 個「協調後正確推薦」以及 4 個「不恰當推薦」。

結論：本研究於樣本代表性以及軸向詞彙內容方面仍需更審慎分析，但於過程與結果中仍能了解，因 ICNP 語義架構概念的特殊性，欲以文字語言分析方式取代專家對應，尚需進行進一步的研究與發展；且在對應過程中發現，ICNP 在特定領域對應到詞彙較少，且於描述負向判斷部分亦較侷限於少部分詞彙，導致無法較精確的描述原 NANDA-I 診斷意義。此外，仍希望藉此為導引，促進護理標準詞彙間的對應，並發揮於臨床應用。

關鍵字

護理資訊 ； 護理標準詞彙 ； NANDA ； ICNP ； 護理診斷

並列摘要

Background - To response the needs of information exchange and analysis, standardized nursing terminology was developed in inevitable. Since the diverse needs of the clinical nursing, the multiple development of standardized terminologies that nursing related also presented. In the part of them, NANDA-I was developed in the earliest, and it is familiar by clinical nurses in Taiwan. NANDA-I provides an efficient way in presenting nursing diagnosis. It uses a pre-defined name to represent a specific diagnosis concept. On the other hand, ICNP offers a structured way to store clinical nursing messages with its special structural design. And the structured design also makes challenges in clinical application. Taiwan Nurses Association has participated in the ICNP development plan at 1999. Furthermore, there are applications and researches published. However, researches and clinical applications in Taiwan decrease after the publication of ICNP version 1.

Purpose – If it is possible to map and connect the high efficient and familiar of NANDA-I with structured design of ICNP, and apply in informatics system which use NANDA-I to record and store with ICNP, it will improve the retrieve of clinical nursing practice records. To assist with the procedure of mapping from NANDA-I to ICNP, this study aim to develop a systematic approach to support it. It is expect to improve the efficient in mapping process.

Method - The purpose of this thesis is to establish a systematic approach to support in mapping with NANDA-I (2012-2014, English version) to ICNP (2011 release, English version). Use the sample with 18 diagnoses that achieve the Level Of Evidence, L.O.E. 2.1 requirement in NANDA-I domain 2 and 3. These diagnoses were mapped by a predetermined rule to ICNP diagnosis indispensible Axis - “Focus” and” Judgment”. This study ranks the mapping terminologies with its high-related, and provides the rank list with recommended.

Results – On those recommended terminologies which with ICNP codes, the nursing experts complete the evaluation in a questionnaire. In the mapping degree, there are 7 diagnoses mapped completely, 5 diagnoses partially mapped and 6 diagnoses with no match. In the correct mapping evaluation, 9 diagnoses are correct recommended, 5 diagnoses are corresponding recommended and 4 diagnoses are incorrect recommended.

Conclusion – This study needs to further analysis in sample representativeness and terminologies content of axes. But we still understood from the process and results, due to the particularity of the ICNP semantic architecture concept, trying to use text language analysis to replace the expert mapping, still needs to further research and development. And through the mapping process, the terminologies that describe negative judgment are lack for use, and it also happens in specific domain. In addition, it is expected to serve as a guide to promote the mapping between nursing standards and work in clinical application.

並列關鍵字

nursing informatics ； nursing terminology ； NANDA ； ICNP ； nursing diagnosis

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