Nursing diagnoses and operational definitions for people with chronic pain

Abstract

Objective  To validate nursing diagnosis statements and their operational definitions from the terminological subset of the International Classification for Nursing Practice for the care of people with chronic pain in Primary Health Care.

Methods  This descriptive research had a quantitative approach with a validity assessment stage by experts. Nursing Diagnoses were developed from a term bank. The organization of both statements and their operational definitions was based on Meleis’ theory of transitions. Their validity was assessed in early 2023 by 60 Brazilian nurses and five Portuguese nurses. Statements with an agreement rate ≥80% were considered validated.

Results  A total of 152 Nursing Diagnosis statements and their respective operational definitions were prepared. After validity assessment, reassessment, and correction by experts, 144 validated statements remained and eight were excluded.

Conclusion  Validation of 144 nursing diagnosis statements and their operational definitions based on the terminological subset of people with chronic pain shows that the practice of Primary Health Care nurses and those who research the topic has proximity with the corresponding content. The construction of Nursing Diagnoses and their operational definitions strengthens nursing as a science, allowing nurses to consider various manifestations resulting from chronic pain and intervene safely and accurately.

Keywords
Nursing diagnosis; Nursing process; Standardized nursing terminology; Validation study; Chronic pain; Primary health care

Resumo

Objetivo  Validar enunciados de diagnósticos de enfermagem e suas definições operacionais do subconjunto terminológico da Classificação Internacional para a Prática da Enfermagem para o cuidado à pessoa com dor crônica na atenção primária à saúde.

Métodos  Pesquisa descritiva, com abordagem quantitativa, com etapa de avaliação de validade por especialistas. Foram elaborados enunciados de Diagnósticos de Enfermagem a partir de um banco de termos. A organização dos enunciados e de suas definições operacionais foi fundamentada na teoria das transições de Meleis. A avaliação de validade foi realizada no início de 2023 por 60 enfermeiros brasileiros e cinco enfermeiros portugueses. Foram considerados validados os enunciados com índice de concordância maior ou igual a 80%.

Resultados  Foram elaborados 152 enunciados de Diagnósticos de Enfermagem e suas respectivas definições operacionais. Após a avaliação de validade pelos especialistas, reavaliação e correções, restaram 144 enunciados validados e oito excluídos.

Conclusão  A validação de 144 enunciados de diagnósticos de enfermagem e suas definições operacionais do subconjunto terminológico à pessoa com dor crônica demonstra a aproximação do conteúdo com a prática dos enfermeiros da Atenção Primária à Saúde e enfermeiros que pesquisam sobre a temática. A construção de Diagnósticos de Enfermagem e suas definições operacionais fortalece a profissão como ciência e permite que enfermeiros consigam contemplar diversas manifestações decorrentes da dor crônica e intervir de forma segura e acurada.

Descritores:
Diagnóstico de enfermagem; Processo de enfermagem; Terminologia padronizada em enfermagem; Estudo de validação; Dor crônica; Atenção primária à saúde

Resumen

Objetivo  Validar enunciados de diagnósticos de enfermería y sus definiciones operacionales del subconjunto terminológico de la Clasificación Internacional para la Práctica de Enfermería para el cuidado de personas con dolor crónico en la atención primaria de salud.

Métodos  Estudio descriptivo, de enfoque cuantitativo, con etapa de evaluación de validez por especialistas. Se elaboraron enunciados de diagnósticos de enfermería a partir de un banco de términos. La organización de los enunciados y sus definiciones operacionales se basó en la teoría de las transiciones de Meleis. La evaluación de validez fue realizada a comienzos de 2023 por 60 enfermeros brasileños y cinco enfermeros portugueses. Se consideraron validados los enunciados con índice de concordancia mayor o igual a 80 %.

Resultados  Se elaboraron 152 enunciados de diagnósticos de enfermería y sus respectivas definiciones operacionales. Después de la validación por parte de los especialistas, la revaluación y las correcciones, quedaron 144 enunciados validados y ocho excluidos.

Conclusión  La validación de 144 enunciados de diagnósticos de enfermería y sus definiciones operacionales del subconjunto terminológico para personas con dolor crónico demuestra la aproximación del contenido con la práctica de los enfermeros en la atención primaria de salud y enfermeros que investigan sobre la temática. La elaboración de diagnósticos de enfermería y sus definiciones operacionales fortalece la profesión como ciencia y permite que los enfermeros puedan contemplar diversas manifestaciones resultantes del dolor crónico e intervenir de forma segura y precisa.

Descriptores:
Diagnostico de enfermería; Proceso de enfermeira; Terminología normalizada de enfermeira; Estudio de validación; Dolor crónico; Atención primaria de salud

Introduction

The nursing diagnosis (ND) that is part of the Nursing Process (NP) is a title given to health findings, events, situations, or conditions.(¹,²) NDs result from an initial assessment in which nurses collect data and identify phenomena that will be the focus of nursing care for individuals, families, communities, or groups. It is necessary that the NDs be based on theoretical constructs and are recorded using appropriate terminology.(¹,²) It shows the contribution of nursing to health care as a consistent recording instrument.(³)

The International Council of Nurses (ICN) developed the International Classification for Nursing Practice (ICNP^®) as a terminology that represents nursing practice in the global setting. The ICN recommends that terminology subsets be developed to facilitate their use. They are groupings of nursing diagnoses, outcomes (NO), and interventions (NI) for health priorities, specialties, and/or clientele.(⁴)

Chronic pain is a priority whose prevalence varies in the range of 23.0-76.2% of the general population in Brazil.(⁵) It is costly for care services and affected individuals.(⁶) In addition, affected people suffer impacting the social, emotional, community, and spiritual dimensions, in addition to aspects of daily life.(⁷)

The accuracy of NDs directs unique interventions related to the needs of people with chronic pain.(⁸) The multidimensional nature of chronic pain requires nurses to have knowledge that allows to identify pathophysiology, behavioral, cultural, and spiritual issues.(⁹)

The identification of an accurate ND requires clarity of statement and an adequate operational definition.(¹⁰) Terminological subsets with operational definitions enhance the precise selection of ND indicators.(¹¹) The stage for constructing and assessing the validity of operational definitions is supported by the Nursing theory that subsidizes the subset. In this study, Meleis’ transition theory was used(¹²)for its ability to seek behavioral changes and knowledge incorporation. They positively reflect the coping and adaptation processes, helping to achieve satisfactory indicators for managing and controlling chronic pain. Transitions may present conditions that facilitate or inhibit the healthy transition process related to personal, social, and community factors.(¹²)

The objective of the present study was to validate the content of statements and operational definitions of nursing diagnoses in the terminological subset of ICNP^® for the care of people with chronic pain in primary health care.

Methods

This descriptive research had a quantitative approach with a validity assessment stage by experts. It is part of the project entitled “Chronic pain: good practices for nursing care using the ICNP^® terminology subset based on the theory of transitions”, which involved researchers from three States (Amazonas, Bahia, and Paraná) in Brazil.

To develop the ND statements, the empirical basis resulting from previous stages of the matrix research was used. It was composed of 3,483 terms mapped between those on nursing care for people with chronic pain identified in the literature and ICNP^® (2019/2020).

The terms were organized according to the ICNP^® (2019/2020) ND statements and criteria of the current standard (ISO 18104:2014) during the execution of the stage updated in 2023.(¹³) Terms expressed as either clinical findings or a term from the “focus” axis and another from the “judgment” axis were used. Terms from the “time”, “location”, and “client” axes were included when relevant.

The operational definitions were developed according to the steps of Waltz, Strickland, and Lenz:(¹⁴) literature review, mapping of concept meaning, and affirmation of operational definition. The following items were used for the review: language and technical dictionaries in the health field; definitions of ICNP^® terms; definitions of the North American Nursing Diagnosis Association International (NANDA-I); and validated definitions for the NDs and NOs of other nursing subsets or terminologies. When a definition was not found in the cited sources, an unsystematic search was carried out in the scientific literature.

The results of the review were organized into charts containing six columns: ND and NO statements; definition from the Portuguese language dictionary (by term and/or concept); definition from the technical dictionary; definition from ICNP^®; definitions from other subsets; definitions from NANDA-I and/or those validated in other terminologies; and the operational definition elaborated. The operational definition occurred by grouping similar and/or complementary information in each identified definition and analyzing the relevance according to Meleis’ theory. The statements and their operational definitions were organized into the personal, community, and social dimensions. The personal dimension was divided into four subcategories due to its extent and complexity: meanings; cultural attitudes and beliefs; socioeconomic status; and preparedness and knowledge for the transition process.

We chose to use the original definition of ICNP^® NDs, which considers the theoretical and necessary aspects in the context of chronic pain without the need to assess validity by experts.

Its validity was assessed when experts confirmed the relevance of a given statement in the context of caring for people with chronic pain. Likewise, the operational definitions were validated when experts confirmed the relevance of the definition presented for the ND statement.

There is no consensus regarding the number of experts to assess the validity of the statements and their operational definitions; however, there is convergence in establishing minimum criteria such as knowledge, experience, and capacity for critical thinking on the subject.(¹⁵) Thus, experts were intentionally selected and then divided into three groups using selection criteria to qualify them.

Group 1 consisted of 30 Brazilian nurses specializing in pain, who were selected for their authorship of articles on chronic pain. A search was carried out in the Virtual Health Library (BVS), Scientific Electronic Library Online (SciELO), and journal portal of the Coordination for the Improvement of Higher Education Personnel (CAPES) using the descriptors “nursing” AND “chronic pain”. To search for authors, articles in Portuguese published between 2013 and 2023 were included; duplicate articles and those unrelated to the topic were excluded despite the descriptors. This stage was operationalized by two scientific initiation students of the parent project.

Experts were selected based on adapted criteria scores(¹⁶) and those identified on the Lattes platform: master or Ph.D. (3 points); publication in the area of ND (2 points); speaker at pain-related events (1 point); and care experience (1 point). A total of 58 nurse authors were identified and 30 of them with the highest score were invited to participate in the research.

Group 2 was formed by 30 nurses from the Primary Health Care (PHC) in a city in the State of Paraná. The selection of PHC nurses was justified by the need to bring research closer to the clinical practice of nurses. Participants were selected by invitation after being indicated by the Municipal Health Department. Nursing assistants with at least two years of experience were included; those who did not care for adults or elderly people with complaints of chronic pain in their weekly routine were excluded.

Group 3 was formed by five nurses working in services providing care to people with chronic pain in a district of Portugal. The selection of Portuguese nurses was justified because there is an ICNP^® research and development center there which is accredited by ICN. Furthermore, ICNP^® is the basis of the terminology used in those health services(¹⁷) where nurses apply Meleis’ theory in various contexts. Participants were selected by invitation after being indicated by professors at a university in the city of Porto (Portugal). Care nurses with at least two years’ experience, who carry out nursing consultations to adults or elderly people with complaints of chronic pain in their weekly routine were included. Given the characteristic of intentional selection, exclusion criteria were not used.

The initial sample of the three groups totaled 65 nurses and the final sample was 23 nurses: 12, 7, and 4 nurses, from groups 1, 2, and 3, respectively.

Data was collected from January to March 2023. A form in the Qualtrics Research Suite^® software was used, containing the Free and Informed Consent Form (FICF), information on the characterization of participants, and three blocks with diagnostic statements and their operational definitions. Three response options were offered to the questions “Is the (ND/NO) statement relevant to this phenomenon?” and “Is the operational definition relevant to ND?”: 1) yes; 2) yes, but with a need for correction/adaptation; and 3) no. A mandatory justification was requested (in an open field) if the experts marked options 2 or 3. Participants received the questionnaire with exclusive access links to each block, with distinct sequences to facilitate completion and adherence to the survey. The statements were analyzed in blocks according to the number of responses per group of experts. To compose the analysis, an amount ≥30% of questions answered per participant was established.

The data were analyzed by percentage of the agreement rate (AR); it was calculated by dividing the number of participants who agreed by the total number of participants and multiplying the ratio by 100. In all groups, statements with AR ≥80% were validated. Statements with AR in the range of 70-79% underwent analysis of the justifications, with subsequent correction; statements with AR ≤69% were excluded.

The statements that needed editing were reviewed by the parent project’s research team. Relevant suggestions supported by the literature were included. The justifications for not validating statements were analyzed based on the literature.

The operational definitions are available in: https://doi.org/10.5281/zenodo.13293045.

The project was approved by the Research Ethics Committee of the Pontifical Catholic University of Paraná (Opinion: 4,333,407; Certificate of Presentation of Ethical Appreciation: 38762020.7.0000.0020; October/2021), Municipal Health Department (Opinion: 4,683,268; Certificate of Presentation of Ethical Appreciation: 38762020.7.3001.9587; April/2021), and Porto School of Nursing (Opinion: Ata 4; March/2023).

Results

A total of 152 ND statements and their operational definitions were prepared; of these, 131 (86.2%) NDs were negative or risky and 21 (13.8%) NDs were positive or chance (potential). The personal dimension had the highest occurrence of NDs (84.0%), followed by the community (10.0%) and social (6.00%) dimensions. In the personal dimension, NDs related to the attribution of meanings (76.0%) and preparation and knowledge for the transition (17.0%) were more frequent. The statements of NDs according to the Transitions Theory, ARs of the statements, and their operational definitions are presented in Table 1. Initially, 138 statements and definitions were validated. Two statements were not validated: “dizziness” and “positive pride”. The experts justified adequacy in 12 ND statements and definitions. Of these, five were maintained after adaptation: “relationship problem”, “risk for spiritual distress”, “obese”, “overweight”, and “altered blood pressure”; six were excluded: “hostility”, “peripheral oedema”, “symptom control”, “lack of symptom control”, “excess food intake”, and “risk for difficulty with coping”. The “constipation” statement was maintained after contextual analysis although not validated in the group of Portuguese nurses (they prefer the term “obstipation”. In the end, 144 validated statements (94.7% of the total) remained.

Table 1
Nursing diagnosis statements organized according to the Transition Theory dimensions and the respective Agreement Rates (AR) with nursing diagnosis (ND) statements and operational definitions (OD)

Nursing diagnosis statements	ND AR (%)*	OD AR (%)†
Personal dimension: Meanings
Anxiety	100.00	90.48
Drug abuse	100.00	100.00
Impaired adherence	100.00	100.00
Agitation	89.47	100.00
Agony	88.89	83.33
Impaired active range of motion	89.47	94.74
Impaired appetite	94.74	94.74
Impaired psychomotor activity	95.24	‡
Lack of self-awareness	94.12	82.35
Self-awareness	88.24	88.24
Self-medication	94.74	89.47
Impaired autonomy	100.00	94.12
Good mood	82.35	94.12
Muscle cramp	94.74	94.74
Impaired ability to walk	95.24	95.24
Impaired ability to perform leisure activities	95.24	100.00
Impaired ability to shop	90.48	85.71
Impaired ability to manage exercise regime	90.48	90.48
Impaired ability to participate in care planning	90.48	90.48
Colic	90.48	‡
Self-destructive behavior	100.00	94.44
Aggressive behavior	100.00	100.00
Constipation	76.19	‡
Inadequate pain control	94.74	100.00
Pain control	94.74	94.74
Symptom control	78.95	89.47
Lack of symptom control	84.21	89.47
Guilt	85.71	‡
Self-care deficit	100.00	95.00
Helplessness	90.48	‡
Discomfort	100.00	100.00
Impaired sexual functioning	94.74	94.74
Hopelessness	94.44	100.00
Despair	95.24	‡
Disillusion	94.44	100.00
Risk for difficulty with coping	76.47	76.47
Difficulty coping with pain	94.12	88.24
Coping with pain	94.12	94.12
Dyspepsia	90.48	‡
Chronic arthritic pain	100.00	‡
Cutaneous Pain	100.00	‡
Chronic musculoskeletal pain	100.00	‡
Chronic vascular pain	100.00	‡
Peripheral oedema	76.47	88.24
Medication Side Effect	100.00	89.47
Risk For Medication Side Effect	89.47	84.21
Migraine	95.24	‡
Impaired balance	89.47	89.47
Muscle spasm	94.44	94.44
Hope	85.71	‡
Stress overload	95.24	90.48
Unrealistic expectation about treatment	94.44	94.44
Fatigue	100.00	94.12
Lack of appetite	94.74	84.21
Lack of trust	88.24	82.35
Lack of response to treatment	89.47	84.21
Tingling	88.89	94.44
Weakness	88.24	94.12
Increased heart rate	88.24	88.24
Frustration	94.12	100.00
Impaired musculoskeletal system function	94.12	94.12
Hostility	76.19	‡
Depressed mood	100.00	100.00
Risk for depressed mood	100.00	94.74
Impotence	95.24	‡
Inflammation	82.35	88.24
Deficient food intake	89.47	84.21
Excess food intake	84.21	78.95
Impaired fluid intake	84.21	94.74
Adverse medication interaction	88.24	94.12
Activity intolerance	100.00	100.00
Risk for activity intolerance	94.74	100.00
Injury	100.00	100.00
Fear	100.00	100.00
Fear about medication side effects	88.89	100.00
Fear about abandonment	94.12	88.24
Fear about being a burden to others	100.00	94.12
Impaired mobility	100.00	89.47
Nausea	100.00	84.21
Obese	89.47	73.68
Overweight	84.21	73.68
Positive pride	61.90	‡
Preoccupation	94.12	94.12
Altered blood pressure	78.95	73.68
Burning	83.33	77.78
Anger	100.00	100.00
Impaired psychological response to pain	88.24	88.24
Risk for fall	100.00	89.47
Satisfaction with pain management	94.12	94.12
Suffering	100.00	100.00
Impaired sleep	94.74	94.74
Somnolence	94.74	89.47
Sadness	100.00	100.00
Dizziness	68.42	84.21
Vomiting	84.21	89.47
Risk for negative quality of life	100.00	100.00
Personal dimension: Attitudes and beliefs
Spiritual Distress	94.74	94.74
Risk for spiritual distress	78.95	84.21
Positive attitude toward care	89.47	94.74
Conflicting attitude toward care	94.74	84.21
Low self-esteem	100.00	95.00
Decisional conflict	95.24	90.48
Impaired role performance	90.48	90.48
Personal dimension: Socioeconomic Status
Problem with Medication Procurement	89.47	89.47
Financial problem	84.21	89.47
Personal dimension: Preparation and Knowledge
Acceptance of aging	94.74	89.47
Impaired acceptance of aging	94.74	89.47
Acceptance of health status	100.00	90.48
Impaired acceptance of health condition	95.24	90.48
Effective self-control	100.00	94.74
Low self-control	94.74	89.47
Self-efficacy	94.12	94.12
Able to perform health maintenance	90.48	95.24
Impaired health-seeking behavior	100.00	100.00
Lack of knowledge of disease	100.00	95.00
Lack of knowledge about exercise	95.00	85.00
Lack of knowledge of pain management	90.00	100.00
Lack of knowledge of behavior change process	95.00	95.00
Lack of knowledge of treatment regime	95.00	95.00
Demotivation	100.00	100.00
Readiness for effective coping	82.35	82.35
Readiness for effective decision making	82.35	88.24
Readiness to learn	89.47	89.47
Treatment exhaustion	100.00	94.74
Lack of resilience	88.24	82.35
Reduced willpower	94.12	94.12
Denial	100.00	90.00
Community dimension
Lack of family support	100.00	94.44
Lack of emotional support	88.24	94.12
Positive caregiver attitude	94.12	94.12
Caregiver able to perform caretaking	82.35	82.35
Readiness for effective community coping	88.89	88.89
Readiness for positive family process	88.24	82.35
Caregiver stress	100.00	100.00
Family able to participate in care planning	88.24	82.35
Impaired attachment	94.12	88.24
Impaired caregiver role	100.00	88.24
Impaired family role	94.12	82.35
Relationship problem	82.35	70.59
Impaired family process	95.24	‡
Impaired rapport (relationship of mutual understanding)	82.35	82.35
Risk for loneliness	94.12	88.24
Social dimension
Medication supply deficit	94.74	94.74
Lack of social support	88.89	88.89
Lack of trust in health care provider	100.00	94.12
Social isolation	100.00	94.74
Risk for social isolation	100.00	100.00
Continuity of care problem	95.24	95.24
Risk for impaired psychosocial condition	89.47	100.00
Risk for employment problem	85.71	85.71
Healthcare Satisfaction	94.12	88.24
Vulnerability	82.35	88.24

• * AR_ND: Agreement index for the statement of the nursing diagnosis; † AR_OD: Agreement index for the operational definition; ‡ NDs with definitions in ICNP^®

The invalidity of the ND statement “Dizziness” was justified by its being too broad, without direct relation to chronic pain. The ND statement “Positive pride” was listed as ambiguous: it can be interpreted as a positive phenomenon, favoring the individual’s transition and indicating personal strengthening or negative if related to resistance to adopting new behaviors.

Discussion

The amount of NDs highlights the amplitude of phenomena involved in the particularities of people with chronic pain. Selecting appropriate NDs for people with chronic pain is challenging. Therefore, operational definitions are crucial because they represent essential attributes of clinical reasoning.(¹⁸)

The validity of negative or risky NDs leads to the reflection that nurses’ assessment prioritizes phenomena that negatively influence health recovery. The result of the analysis reveals the complex condition of chronic pain. However, care focused on negative factors will limit facilitators of transition, such as therapeutic adherence and coping.

In personal factors, facilitating or inhibiting conditions are classified according to their relationship with: the meaning attributed to them; the attitudes and cultural beliefs; socioeconomic status; and the level of preparedness and knowledge to face the transition process.(¹²) Among the pillars of the Theory of Transitions, we highlight the NDs of the personal dimensions and those of the social and community dimensions (although in smaller quantities), explaining the overcoming of views limited to individuals and physiopathology.

In the factors related to the meanings of the conditions of the personal dimension, the validity of the NDs and DOs “fear”, “anger”, “suffering”, and “sadness” shows that experts recognize the direct relationship between chronic pain and emotional phenomena. Emotional aspects play an important role in the way people interpret and use their resources to deal with their pain,(¹⁹)and may imply treatment adherence, interfering with quality of life.

The inclusion of NDs in ICNP^® expands the representation of nursing phenomena. The new statements “Disillusion” and “Demotivation” consider emotional aspects related to impaired engagement that permeate chronic pain and inhibit a healthy transition. Lack of expectations and motivation increases pain intensity, makes it difficult to achieve adaptive measures, and impairs autonomy and pain management.(²⁰)

The ND “aggressive behavior” contributes to identifying its underlying cause. Aggressive behavior may be linked to anger and frustration, which are related to inadequate pain management and may add to non-cooperative attitudes, procrastination, and lack of communication.(²¹)

The NDs “anxiety” and “depressed mood” are responses from people in pain. A study that analyzed the prevalence of anxiety, depression, and mixed anxiety and depression disorder in women with chronic pelvic pain, concluded that they were more anxious compared to those who did not have these characteristics.(²²)

People’s physical capacity interferes with treatment for chronic pain. The NDs “discomfort”, “injury”, “fatigue”, “risk for activity intolerance”, “impaired mobility”, and “impaired balance” show the importance of assessing the physical conditions associated with chronic pain that require nursing attention.

The ND “risk for fall” is relevant because chronic pain is prevalent in the elderly. By identifying ND, reducing disabilities and preventing exacerbations are expected.(²³)

Regarding the attitudes and beliefs of individuals, objective and subjective data show that spiritualized individuals, with positive beliefs and hope present improvement in symptoms and adherence to treatment, developing control strategies for crises and clinical manifestations.(²⁴)

The ND “low self-esteem” is related to the opinion about oneself, the vision of one’s value and capabilities, verbalization of beliefs, and self-confidence,(²)being necessary to help these people recover their self-esteem and perception of their history.(²⁵)

The NDs “spiritual distress” and “decision conflict” highlight the needs of individuals that should not be neglected as they represent subjectivities that are difficult to identify. Therefore, their operational definitions contribute to recognizing their attributes.

Concerning the socioeconomic aspects of the personal dimension, chronic pain can cause absenteeism and temporary or permanent disability causing financial and access-to-treatment difficulties. Evidence shows that low socioeconomic status is related to a moderate increase in chronic pain.(²⁶) Therefore, nurses should realize the influence of economic conditions on chronic conditions, and the NDs “financial problem” and “problem with medication procurement” can represent them.

To achieve a healthy transition, a systemic and integrative approach that enhances effective measures is important. The NDs “acceptance of health condition” and “effective self-control” are indicators of positive processes that should be reinforced and shared among professionals in therapeutic planning. In contrast, the NDs “impaired health-seeking behavior”, “demotivation”, “denial”, “treatment exhaustion”, and “lack of knowledge of treatment regime” are objects for a cooperative discussion aimed at (re)aligning care plans.

As for aspects related to the community dimension, we understand that people with greater social and community support may have a chance of experiencing a satisfactory transition.(²⁷) The NDs “lack of family support” and “risk for loneliness” indicate that the quantity and/or quality of support offered to individuals is deficient. The deficit may be related to either “caregiver stress” or “impaired rapport”.

The role of the family stands out in the lives of people with chronic pain based on the following statements: “family able to participate in care planning”, “impaired family role”, and “readiness for positive family process”. A study on the impact of chronic pain on quality of life concluded that the theme of pain interference with relationships and family life was among the emerging themes.(²⁸) This leads us to reflect that nursing care planning must include the family in the process of dealing with chronic pain.

Regarding the transition conditions related to the social dimension, the ND “Vulnerability” is relevant although it is not included in the ICNP^®. Vulnerability with other determinants may indicate difficulty in adopting coping strategies, leading to ineffective adaptation.(²⁹) Chronic pain is associated with sociodemographic and clinical variables that, together, may interfere with the management and control of pain,(⁵) prevailing in historically vulnerable groups, such as women and the elderly(⁵) and people with low education and no work activity.(²⁹)

In many contexts, chronic pain has stigmas of punishment or chastisement that can lead people not to seek health care or not adhere to relief measures, causing feelings of agony and suffering. Factors such as negative beliefs, despair, or pain catastrophizing can directly influence both control of chronic pain and perception of pain-related disability.(³⁰)

Finally, the experts’ justifications for non-validated statements and definitions show detail and compromise that imply the quality of results.

The low adherence of experts was a limitation although minimized by dividing the questionnaire into blocks. We suggest carrying out both cross-cultural adaptation of the statements and operational definitions into European Portuguese and submission of the concepts to the ICN as future steps.

Conclusion

The validity of 144 nursing diagnosis statements and the operational definitions of the terminological subset for people with chronic pain shows the proximity of the content to the practice of clinical nurses and researchers. The construction of nursing diagnoses and their operational definitions, guided by a terminology established and supported by a nursing theory, strengthens the nursing profession as a science allowing nurses to face the complex manifestations of chronic pain and perform safe interventions. The use of Meleis’ Theory favored the elaboration of definitions considering the different dimensions affected by chronic pain. Nursing diagnoses and operational definitions for the care of people with chronic pain can establish a standard of care that represents the reality experienced by them and must also be recorded in computerized systems.

Acknowledgments

This research was supported by the Araucária Foundation (SUS2020131000004, CP11/2020 PPSUS Edition 2020/2021) and by the National Council for Scientific and Technological Development (CNPq; 403654/2021-1 call CNPq Universal: 18/2021, Track B).

References

• ¹ Conselho Federal de Enfermagem (Cofen). Resolução Cofen nº 736, de 17 de janeiro de 2024. Diário Oficial da União [Internet] 2024 Jan 23 [citado 2024 Jul 20];16(Seção 1):74. Disponível em: https://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?data=23/01/2024&jornal=515&pagina=74
  » https://pesquisa.in.gov.br/imprensa/jsp/visualiza/index.jsp?data=23/01/2024&jornal=515&pagina=74
• ² Garcia TR, Nóbrega MML da, Cubas MR. CIPE ® versão 2019/2020. In: Garcia TR, org. Classificação Internacional para a Prática de Enfermagem (CIPE ® ): versão 2019-2020. Porto Alegre: Artmed; 2020. p. 35-236.
• ³ Rabelo-Silva ER, Dantas Cavalcanti AC, Ramos Goulart Caldas MC, Lucena A de F, Almeida M de A, Linch GF da C, et al. Advanced Nursing Process quality: Comparing the International Classification for Nursing Practice (ICNP) with the NANDA-International (NANDA-I) and Nursing Interventions Classification (NIC). J Clin Nurs. 2017;26(3-4):379-87.
• ⁴ Coenen A, Kim TY. Development of terminology subsets using ICNP ®. Int J Med Inform. 2010;79(7):530-8.
• ⁵ Aguiar DP, Souza CP de Q, Barbosa WJM, Santos-Júnior FFU, Oliveira AS de. Prevalence of chronic pain in Brazil: systematic review. BrJP. 2021;4(3):257-67.
• ⁶ Cohen SP, Vase L, Hooten WM. Chronic pain: an update on burden, best practices, and new advances. Lancet. 2021;397(10289):2082-97.
• ⁷ Silva JP, Jesus-Moraleida F, Felício DC, Queiroz BZ, Ferreira ML, Pereira LS. Biopsychosocial factors associated with disability in older adults with acute low back pain: BACE-Brasil study. Ciênc Saúde Colet. 2019;24(7):2679-90.
• ⁸ Ferrari MF, Daher DV, Antunes JM, Amim EF, Jesus CM, Geraldo MA. Pain as the fifth vital sign, challenges for its incorporation in health training. REME Rev Min Enferm. 2019;23:e-1233. n
• ⁹ Antunes JM, Daher DV, Moraes ÉB de, Ferrari MF, Geraldo M de A. [Integrating program and nursing care with regard to chronic pain]. Enferm. foco. 2020;11(5):48-53. Portuguese.
• ¹⁰ Ramos CR, Lima da Silva JL, Lindolpho MC, Chrizostimo MM, Reis LB, Almeida GL. Diagnostics, results and nursing interventions focused on the community in the covid-19 pandemic. Res Soc Develop. 2020;9(9):e933997400.
• ¹¹ de Souza Carneiro C, Takao Lopes C, de Lima Lopes J, Batista Santos V, Bachion MM, de Barros ALBL. Conceptual and operational definitions of the defining characteristics and related factors of the diagnosis ineffective health management in people with heart failure. Int J Nurs Knowl. 2017;28(2):76-87.
• ¹² Meleis AI. Transitions theory: middle range and situation specific theories in nursing research and practice. Foundations of Art Therapy Supervision. New York: Springer Publishing Company; 2010.
• ¹³ Cubas MR, Silva RS da, Primo CC, Brandão MA, Félix ND, Jensen R. Contributions of representing the elements of nursing practice in the ISO 18.104:2023 standard: a theoretical study. Rev Esc Enferm USP. 2024;58:e20230358.
• ¹⁴ Waltz CF, Strickland OL, Lenz ER. Measurement in nursing and health research. 5th ed. New York: Springer; 2017.
• ¹⁵ Vieira TW, Sakamoto VT, Moraes LC, Blatt CR, Caregnato RC. Validation methods of nursing protocols: an integrative review. Rev Bras Enferm. 2020;73:e20200050.
• ¹⁶ Guimarães HC, Pena SB, Lopes JL, Lopes CT, Barros AL. Experts for validation studies in nursing: new proposal and selection criteria. Int J Nurs Knowl. 2016;27(3):130-5.
• ¹⁷ Escola Superior de Enfermagem do Porto. Centro de Investigação Desenvolvimento em Sistemas de Informação em Enfermagem - CIDESI. Porto: ESEP; 2024.
• ¹⁸ Albuquerque TR, Primo CC, Brandão MA, Oliveira DR, Cubas MR, Cruz RS. ICNP ® subset for breastfeeding: validity of operational definitions, diagnoses, outcomes and interventions. Acta Paul Enferm 2023;36:eAPE01461.
• ¹⁹ Loduca A, Müller BM, Focosi AS, Samuelian C, Yeng LT. [Pain Portrait: a way to understand individual suffering]. Psic Teor Pesq. 2021;37:e37450. Portuguese.
• ²⁰ Rodrigues AC, Cunha AM, Forni JE, Dias LA, Condi PR, Martins MR. Factors that influence the quality of life in neuropathic, musculoskeletal, and oncological pain. BrJP. 2021;4(1):31-6.
• ²¹ Adachi T, Yamada K, Fujino H, Enomoto K, Shibata M. Associations between anger and chronic primary pain: a systematic review and meta-analysis. Scand J Pain. 2022;22(1):1-13.
• ²² Siqueira-Campos VM, Da Luz RA, de Deus JM, Martinez EZ, Conde DM. Anxiety and depression in women with and without chronic pelvic pain: prevalence and associated factors. J Pain Res. 2019;12:1223-33.
• ²³ Régis CD, Dos Santos CT, Einhardt RS, Lucena AF. Chronic pain evaluated by the Nursing Outcomes Classification. J Nurs UFPE on line. 2020;14:e243932.
• ²⁴ Ferreira-Valente A, Damião C, Pais-Ribeiro J, Jensen MP. The role of spirituality in pain, function, and coping in individuals with chronic pain. Pain Medicine. 2020;21(3):448-57.
• ²⁵ Oliveira JP, Berardinelli LM, Cavaliere ML, Rosa RC, Costa LP, Barbosa JS. The routines of women with fibromyalgia and an interdisciplinary challenge to promote self-care. Rev Gaúcha Enferm. 2019;40:e20180411.
• ²⁶ Prego-Domínguez J, Khazaeipour Z, Mallah N, Takkouche B. Socioeconomic status and occurrence of chronic pain: a meta-analysis. Rheumatology. 2021;60(3):1091-105.
• ²⁷ Wilson JM, Colebaugh CA, Flowers KM, Meints SM, Edwards RR, Schreiber KL. Social support and psychological distress among chronic pain patients: the mediating role of mindfulness. Pers Individ Dif. 2022;190:111551
• ²⁸ Hadi MA, McHugh GA, Closs SJ. Impact of chronic pain on patients' quality of life: a comparative mixed-methods study. J Patient Exp. 2019;6(2):133-41.
• ²⁹ Ribeiro AL. A pessoa com dor crónica: um modelo de acompanhamento de enfermagem. Porto (Portugal): Novas Edições Acadêmicas; 2018.
• ³⁰ Silva NC, Cardoso TS, Andrade EA, Battistella LR, Alfieri FM. Pain, disability and catastrophizing in individuals with knee osteoarthritis. BrJP. 2020;3(4)322-7.

Edited by

• Associate Editor:
  Camila Takao Lopes (https://orcid.org/0000-0002-6243-6497) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil

Publication Dates

• Publication in this collection
  07 Nov 2025
• Date of issue
  2025

History

• Received
  20 Aug 2024
• Accepted
  10 Apr 2025