title: Transcultural mapping and usability testing of the clinical care classification system for an Iranian neonatal ICU population.
abstract: The aim of this research study was to map nursing diagnoses and interventions documented and observed in a neonatal ICU to the Clinical Care Classification system and to validate the translation of these mapped diagnoses and interventions into Persian. This descriptive research used directed content analysis to map diagnoses and interventions to the Clinical Care Classification. Documentation reports of nursing care were extracted from a paper-based documentation system for infants hospitalized in April, May, and June 2011. Observations of care were conducted and compared with documentation to itemize any interventions not included in the documented record. Documented reports of nurses' care and recorded observations were analyzed through directed content analysis, and obtained expressions were mapped to the diagnoses and intervention coding system of the Clinical Care Classification and translated into Persian. Validation of the subsequent code translation was obtained from nursing experts using the Delphi method in two rounds. Findings showed the most frequent nursing diagnoses were related to respiratory condition of infants such as mechanical ventilation dependency (21.1%), and the most frequent nursing interventions were related to completing physician orders such as blood sampling and medication administration (23.9%). Only 47.8% of Clinical Care Classification diagnoses and interventions codes were reflected in the data set. The relatively low rate of nursing care documented in therecords could be due to both the lack of a nursingcare delivery framework, such as the nursing process, and the lack of any framework or standardization in the documentation system in this setting. Using a framework for care delivery and a coding system for documentation of care such as the ClinicalCare Classification would allow for the more complete documentation of nursing care and subsequently the ability to track and analyze this care.
authors.affiliation: Author Affiliations: NICU Nursing (Ms Varzeshnezhad), Pediatric NursingDepartment (Dr Rassouli), and Nursing Management Department (Dr Zagheri Tafreshi), Nursing & Midwifery School, Shahid Beheshti University of Medical Sciences; and Payam-E Noor University (Mr Kashef Ghorbanpour), Tehran, Iran; and Department of Adult/Acute Health, Chronic Care and Foundations, School of Nursing, University of Alabama at Birmingham (Dr Moss).
authors.forename: Maryam
authors.initials: M
authors.lastname: Varzeshnezhad
authors.forename: Maryam
authors.initials: M
authors.lastname: Rassouli
authors.forename: Mansoure Zagheri
authors.initials: MZ
authors.lastname: Tafreshi
authors.forename: Reza Kashef
authors.initials: RK
authors.lastname: Ghorbanpour
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Moss
mesh_terms: D003466:Cultural Characteristics; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D007492:Iran