A randomized controlled trial of a nursing

SHORT-TERM EFFIC ACY OF A NURSING PSYCHOTHERAPEUTIC INTERVENTION FOR ANXIETY ON ADULT PSYCHIATRIC OUTPATIENTS: A RANDOMISED CONTROLLED TRIAL Francisco Sampaio Odete Araújo

Carlos Sequeira

Teresa Lluch Canut

Teresa Martins Leiria, 12th May, 2018

Sampaio, F. , Araújo, O., Sequeira, C., Lluch Canut, T., & Martins, T. (2018). Short-term efficacy of a nursing psychotherapeutic intervention for anxiety on adult psychiatric outpatients: A randomised controlled trial. Oral communication presented at 4th International Health Congress “Global Health Trends”, Leiria (Portugal).

AGENDA

• Introduction / Background • Aim • Methods • Results • Conclusion • References

2


INTRODUCTION / BACKGROUND • Several efficacious treatments for anxiety are available, including different forms of psychotherapy and pharmacotherapy (Cuijpers et al., 2013). • In spite of these findings, literature tends to grant more findings from studies about the efficacy of psychotherapies/therapies provided by nurses (e.g. Asl & Barahmand, 2014; Hyun, Chung, De Gagne, & Kang, 2014) than from studies about the efficacy of nursing psychotherapeutic interventions (interventions classified, for instance, on NIC) (Bulechek, Butcher, Dochterman, & Wagner, 2012) such as anxiety reduction or coping enhancement. • Moreover, no studies were to be found in literature about the efficacy of psychotherapeutic interventions on anxiety as a symptom. 3


INTRODUCTION / BACKGROUND Diagnoses Nursing diagnoses (ICNP/NANDA-I) e.g.: o Anxiety o Situational low self esteem o Social isolation o Caregiver stress o Impaired eating behaviour o Relationship problem o Disturbed body image o Risk for self destructive behaviour o Risk for situational low self esteem

Integrative approach Therapeutic relationship Setting (inpatient or outpatient)

Structure Brief to medium-term (3-12 sessions) Interpersonal communication nurse-patient Sessions’ length (45-60 minutes) Interventions

Nursing psychotherapeutic interventions (NIC): oCognitive restructuring oAssertiveness training oCrisis intervention oCoping enhancement oImpulse control training oBody image enhancement oRelocation stress reduction oSelf-esteem enhancement oRole enhancement oBehaviour modification

Outcomes Nursing outcomes (NOC) e.g.: o Anxiety level o Self-esteem o Social involvement o Caregiver wellbeing o Caregiver emotional health o Nutritional status: Food & fluid intake o Social interaction skills o Body image o Suicide selfrestraint

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INTRODUCTION / BACKGROUND Brief psychodynamic approach techniques

Initial assessment (Session 0)

t ee m Referral to to ion n e s r other io ilu clu us Fa e in excl healthcare th or ia r professionals / e / d crit an services

Fu lfi inc lmen ex clu lusio t of t sio n a he n c nd rite Identifying NANDA-I / ria ICNP nursing diagnoses (Session 1)

Problem of the past, which is stored in the unconscious, with impact on the present

Providing nursing psychotherapeutic intervention(s) – NIC (Sessions 2-4)

Cognitive approach techniques

Cognitive problem

Behavioural approach techniques

Behavioural problem

Evaluating nursing outcomes – NOC (Session 5)

Humanistic approach techniques

Problem with which the patient has intrinsic capacity to deal with

Note: The displayed number of sessions is merely an average reference. 5


F.M.C. Sampaio et al. / Archives of Psychiatric Nursing 31 (201

INTRODUCTION / BACKGROUND

Heisel, M. J., Duberste personal psycho Professional Psych 1037/a0014731. Herdman, T. H., & Ka Nursing diagnosis Nursing interventions Nursing outcomes Definitions & clas (ICNP/NANDA-I code) (NIC code) (NOC code) Hodge, M. B., Asch, S. Anxiety level (1211) Anxiety Anxiety reduction (5820) dicators of nursi Anxiety self-control (10000477/00146) Coping enhancement (5230) Administration, 3 00010. (1402) Relaxation therapy (6040) Holmes, J. (1995). Ho Counselling (5240) and science of ass Anger control assistance Horatio: European Ps (4640) chotherapy: The Crisis intervention (6160) http://www.hor Relocation stress reduction (accessed 12 July (5350) Huang, S., Li, C., Yang Life story older people wit Research, 17(2), 1 Hyun,6 M., Chung, H. Sampaio, F. , Araújo, O., Sequeira, C., Lluch Canut, T., & Martins, T. (2018). Short-term efficacy of a nursing psychotherapeutic intervention for anxiety on adult psychiatric outpatients: Abehavioral randomised controlled thera th Table 7 NOC Outcomes and NIC Psychotherapeutic Interventions Linkages to Nursing Diagnosis “Anxiety”.

trial. Oral communication presented at 4 International Health Congress “Global Health Trends”, Leiria (Portugal).

AIM

To evaluate the short-term efficacy of a psychotherapeutic intervention model in nursing on Portuguese adult psychiatric outpatients with the nursing diagnosis “anxiety”.

7


METHODS • Design: Single-blind randomised controlled trial (NCT02930473). • Setting: Psychiatry outpatient ward. • Participants: Psychiatric outpatients, aged 18-64, with nursing diagnosis “anxiety”. Participants were randomly allocated to an intervention group (n = 29) or a treatment-as-usual control group (n = 31). • Intervention: NIC psychotherapeutic interventions plus pharmacotherapy (if applicable) vs. Pharmacotherapy (if applicable). • Outcomes: Anxiety level and anxiety self-control (NOC outcomes). The time points for assessment were at baseline and post-test (6 weeks after). 8


RESULTS Enrolment

Assessed for eligibility (n= 133) Excluded (n=59) - Not meeting inclusion criteria (n=57) - Declined to participate (n=2) - Other reasons (n=0) Randomised (n= 74)

Allocated to intervention (n=42) - Received allocated intervention (n=32) - Did not receive allocated intervention (patients decided not to participate after being randomised) (n=10)

Allocation

Allocated to control (n=32) - Received usual care (n=32) - Did not receive usual care (n=0)

Post-Test Lost to post-test (unreachable patient) (n=1) Discontinued usual care (n=0)

Lost to post-test (n=0) Discontinued intervention (patients gave no reasons to discontinue the intervention) (n=3)

Analysis Analysed (n=29) - Excluded from analysis (n=0)

Analysed (n=31) - Excluded from analysis (n=0)

9


RESULTS

.

|

9

70

Means

60

Graphic representation of howing the change in NOC nxiety level” and “Anxiety selfs over time for the IG and ur figure can be viewed at rary.com]

50

Anxiety level (control group)

40

Anxiety level (intervention group)

30

Anxiety self-control (control group)

20

Anxiety self-control (intervention group)

10 0

Pre-intervention

Post-intervention

Time period

10


CONCLUSION • This research contributed to validate the efficacy of a psychotherapeutic intervention in nursing in decreasing anxiety levels and improving anxiety selfcontrol in a sample of Portuguese adult psychiatric outpatients with pathological anxiety. • Future research should be double-blind (if possible), should comprise a larger sample, should use an active placebo control group, focus on long-term efficacy and include pragmatic trials to assess the effectiveness and cost-effectiveness of this intervention in the daily clinical practice. • The findings of our study seem to be relevant for the clinical practice as they suggest the efficacy of a psychotherapeutic intervention model in nursing, whose interventions are based on nursing body of knowledge (NIC) and whose evaluation is grounded in nursing outcomes (NOC), on the nursing diagnosis “anxiety” (ICNP/NANDA-I). 11


DISSEMINATION Received: 28 November 2016

Accepted: 12 January 2017

DOI: 10.1111/ppc.12211

ORIGINAL ARTICLE

Nursing psychotherapeutic interventions: a review of clinical studies

Contributes for the development of a psychotherapeutic intervention model in nursing: A focus group study in Portugal and Spain

Francisco Miguel Correia Sampaio* , Carlos Alberto da Cruz Sequeira† and Mar! ıa Teresa Lluch Canut

Francisco Miguel Correia Sampaio RMHN, MSc1,2,3,4

REVIEW

Sequeira RMHN, MSc, PhD5,6,7 Aims and objectives. To summarise current knowledge about nursing psychotherWhat does this paper contribute apeutic interventions in adults. to the wider global clinical Background. In Portugal, the provision of psychotherapeutic interventions is conArchives of Psychiatric Nursing 31 (2017) 147–156 community? sidered a competence of mental health nurses. However, literature is not totally clear about the differences between ‘psychotherapy’ inter• This review provides evidence of Contentsand lists‘psychotherapeutic available at ScienceDirect some specificities related to nursventions’ and about the specific characteristics that define a nursing psychotheraing psychotherapeutic intervenArchives of Psychiatric Nursing peutic intervention. tion, and it aids in understanding Design. Narrative review. j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / a p n uthe differences between a psychoMethods. A literature review utilising MEDLINE, PsycINFO, CINAHL, the Web therapeutic intervention perof Science, Psychology and Behavioral Sciences Collection, and MedicLatina comformed by a nurse and that Content Validity of a Psychotherapeutic Intervention inperformed Nursing: by other health care puterised databases for the period from 2003–2013. A total of 151 eligible Model arti☆ providers. A e-Delphi clesModified were identified. Relevant Study data were extracted, and findings were synthetised • This review makes clear that psyin a narrative synthesis. e Francisco Miguel Correia Sampaio a,b,c,d,⁎, Carlos Sequeira c,d, Teresa Lluch Canutchotherapeutic intervention is Results. Nursing psychotherapeutic interventions are frequently based on ‘CogniInstituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal also a competence of mental Psychiatry Department, Hospital de Braga, Braga, Portugal tive-Behavioural’ rationale. The usual length of these interventions varies between health nurses, which can be helpNursing School of Porto, Porto, Portugal Center for Health Technology and Services Research, Porto, Portugal 5–16 weeks, in a total of 5–12 sessions of 45–60 minutes. The mechanisms of ful in making it available to a Department of Public Health, Mental Health and Perinatal Nursing, Barcelona University School of Nursing, Feixa Llarga, s/n, 08907 L'Hospitalet Ll., Barcelona, Spain larger number of people, thus change are heterogeneous, but the therapeutic relationship between the nurse and improving the quality of the the client tof be factor of nursing a r t i c lseems e i n o the most important a b s positive t r a c predictive t health care assistance. psychotherapeutic interventions. Some of the most used outcome assessment meaAim: To estimate the content validity of a psychotherapeutic intervention model in nursing. Background: Mental health nurses encounter great extrinsic difficulties when it comes to providing psychothersures include the Beck Depression Inventory, the Hospital Anxiety and Depression apeutic interventions due to the fact that they are not allowed to perform such practice in some countries. In this Scale, and the CORE-OM. The effectiveness of nursing psychotherapeutic interlight, the pursuit of a psychotherapeutic intervention model in nursing seems germane to guide the professionals' psychotherapeutic practice, contributing hereof to increase mental health nurses' professional autonomy. ventions has been widely demonstrated in many studies. However, the need of Design: Modified e-Delphi. Methods: were collected from October 2015 to January 2016 by means of three rounds of online questionfurther studies to prove its cost effectiveness is Data evident. naires. The initial questionnaire was structured into five sections: general structure of the model, patients' exclusion criteria, assessment framework, nursing diagnoses, and nursing psychotherapeutic interventions. From the Conclusions. It is necessary to have a better understanding of nursing psychother42 experts invited, at least twenty (20) participated in each round. apeutic interventions, one that explainsResults: its conceptual limits,consensus to improve mental The experts achieved with regard to the conclusion that nursing psychotherapeutic interventions should always seek to address a nursing diagnosis. These defined furthermore that a psychotherapeutic inhealth nursing knowledge and create suitable models of psychotherapeutic intertervention model in nursing should be exercised by means of 3 to 12 sessions using Nursing Interventions Classification (NIC) as a resource. Finally, experts deemed that the model should follow the principles of integravention in nursing. tive psychotherapy, so that techniques from different schools of psychotherapy could therefore be used in conjunction to promote the resolution of a nursing diagnosis. Relevance to clinical practice. The findings of this review can create awareness Conclusion: Achieving consensus about the structure of a psychotherapeutic intervention model in nursing is imfor some weaknesses of nursing knowledge about thenurses psychotherapeutic intervenperative to guide in the provision of nursing psychotherapeutic interventions and to enable an effective evaluation of the health gains associated with its implementation. tion and for the need to produce knowledge, to nurture the nursing discipline in © 2017 Elsevier Inc. All rights reserved.

Accepted: 12 December 2017

1 Instituto

de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal

Abstract

2 Psychiatry

Purpose: To explore the aspects set forth as the minimum set of features that should integrate a

Department, Hospital de Braga, Braga, Portugal

3 Nursing

c

DOI: 10.1111/jan.13520 d e

ORIGINAL RESEARCH: CLINICAL TRIAL

psychotherapeutic intervention model in nursing.

School of Porto, Porto, Portugal

4 Research

Group “NursID: Innovation & Development in Nursing”, Center for Health Technology and Services Research (CINTESIS), Porto, Portugal

Design and Methods: Two focus groups were conducted, with the participation of 15 nursing professionals. Data were analysed thematically.

Findings: Five topics previously identified were analysed: theoretical conceptualization, structure, Evaluation of the Psychometric Properties Pedagogical Unit, “Nursing: Discipline patients’ inclusion and exclusion criteria, operationalization, and evaluation of the intervention(s) & Profession,” Nursing School of Porto, Porto, effectiveness. Theoretical conceptualization has been mainly grounded on Peplau’s theory. Moreof NOC Outcomes “Anxiety Level” and “Anxiety Portugal over, participants believe that standardized nursing language and nursing process should be the Research Group “NursID: Innovation & Devel- in a Portuguese Outpatient Sample Self-Control” presumptions of the model.

5 Scientific

6

opment in Nursing” CINTESIS, Porto, Portugal

7 Portuguese Francisco Miguel Correia RMN, MSc, Odete Sofia Silva Lomba Araújo, RMN, MSc, PhD, Society of Mental HealthSampaio, Nursing,

Practice study allowed the identification of a minimum set of features that Carlos Alberto da Cruz Sequeira, RMN, MSc, Implications: PhD, María This Teresa Lluch Canut, RMN, PhD, and Porto, Portugal Teresa Martins, RN, MSc, PhD

a

b

Carlos Alberto da Cruz

María Teresa Lluch Canut RMHN, PhD8

8 Department

should integrate a psychotherapeutic intervention model in nursing, about which consensus must

of Public Health, Mental Health Francisco Miguel Correia Sampaio, RMN, MSc, is a PhD Student at Instituto de Ciências Biomédicas Abel Salazar, University of be reached with a view to itsde further development. andPorto, Perinatal Nursing, Barcelona University Registered Nurse at the Psychiatry Department, Hospital Braga, Invited Assistant at Nursing School of Porto and Researcher at Research School of Nursing, Barcelona, SpainGroup “NursID: Innovation & Development in Nursing”, Center for Health Technology and Services

Research, Porto, Portugal, Odete Sofia da Silva Lomba de Araújo, RMN, MSc, PhD, is an Associate Professor (Invited) at School of Nursing, University of Minho, Braga, Portugal, Carlos Alberto da Cruz Sequeira, RMN, MSc, PhD, is an Associate Professor Correspondence KEYWORD S at Nursing School of Porto and Principal Investigator at Research Group “NursID: Innovation & Development in Nursing”, Francisco Miguel Correia Sampaio, Psychiatry focusResearch, groups, nursing, nursing models, psychotherapy, qualitative research Center for Health Technology and Services Porto, Portugal, María Teresa Lluch Canut, RMN, PhD, is a Full Professor Department, Hospital de Sete Fontes, Mental Health and Perinatal Nursing, University School of Nursing, University of Barcelona, at Department ofBraga, Public Health, Barcelona, Spain, and Teresa Martins, RN, MSc, PhD, is an Associate Professor at Nursing School of Porto and Researcher at 4710-243 São Victor, Braga, Portugal. Research Group “NursID: Innovation & Development in Nursing”, Center for Health Technology and Services Research, Porto, Email: [email protected], Portugal

with a copy to the Editor: [email protected] Search terms:

PURPOSE: To adopt the language and to evaluate the psychometric properties of “Anxiety level” and “Anxiety self-control” NOC outcomes in Portuguese adult patients. METHODS: Methodological design.

Anxiety, nursing outcomes classification, psychometrics

1

I N T RO D U C T I O N

be superior at providing psychotherapeutic interventions than any

FINDINGS: The final European Portuguese version of the NOC outcome “AnxiAuthor contact: 5 indicators, proved excellent internal consistency. Exby 16 [email protected], ety level,” composedother. ploratory factor analysis (EFA) was forced to three factors. The NOC outcome with a copy to the Editor: 1 states “Anxiety self-control,” composed of nine indicators, a effectiveness questionable Several studies were conducteddemonstrated to recognise the of Portuguese that providing psychotherapeutic care is a [email protected] internal consistency. EFA was forced to two factors. nursing psychotherapeutic interventions counselling for patients European Portuguese versions of the (e.g., studied NOC outcomes proved to be tools with acceptable psychometric properties for evaluating anxiety

A randomized controlled trial of a nursing psychotherapeutic intervention for anxiety in adult psychiatric outpatients Authors: Francisco Miguel Correia Sampaio, PhD Student at Instituto de Ci^ encias Biom! edicas Abel Salazar - Universidade do Porto,

Fostered by the position paper emanated by Horatio: European Porto, Portugal, Registered Mental Health Nurse at Hospital de Psychiatric Nurses (2012), the discussion about mental health nurses' training capability to provide Braga, psychotherapeutic interventions has Braga - and Psychiatry Department, Portugal, and Invited Assisbeen widely spread in the last few years, which substantiates the need tant at Porto Nursing School, Porto, Portugal; Carlos Alberto da for this study. Cruz Sequeira, RMHN, MSc, PhD, Associate Professor at Porto There are indeed some European countries where only psychiatrists and psychologists allowedPedagogical to provide psychotherapeutic intervenNursing School - are Scientific Unit “Nursing: Discipline tions (Ward, 2015), which runs against the advice of relevant interna& Profession”, Coordinator the Research tional associations Porto, such as Portugal, the European Association of for Psychotherapy

Group “NurID: Innovation & Development in Nursing” - CINTESIS-FMUP, Porto, Portugal; Mar! ıa Teresa Lluch Canut, RMHN, PhD, Full Professor of Psychosocial Nursing and Mental Health at

☆ This paper has not been published or submitted for publication elsewhere. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. We have no conflicts of interest to disclose. ⁎ Corresponding Author: Francisco Miguel Correia Sampaio, RMHN, MSc, PhD Student, Sete Fontes - São Victor, 4710-243 Braga, Portugal. E-mail addresses: [email protected] (F.M.C. Sampaio), [email protected] (C. Sequeira), [email protected] (T. Lluch Canut).

Barcelona University School of Nursing - Department of Public Health and Perinatal Nursing, Barcelona, Spain.

(2009) and the World Council for Psychotherapy (2012). That is even Correspondence: Francisco Miguel Correia Sampaio, PhD Student, more grievous if we consider that it runs against all the evidence of the contrary. An example is, Gournay, Denford, Parr, Newell (2000), Registered Mental Health Nurse at Hospital de and Braga – Psychiatry who undertook a 25-year follow up of nurses working in behavioral psyDepartment, Sete Fontes, 4710-243 S~ ao Victor, Braga, Portugal. chotherapeutic intervention in the UK, which enabled them to prove that Telephone: these nurses+351253027000. had made considerable contribution to mental health service provision, specifically in primary health care, by means of brief E-mail: [email protected] and short-term psychotherapeutic interventions. On the other hand, some European countries bring forth a more in*Member of ‘The Portuguese Society of Mental Health Nursing’ clusive regulation related to the psychotherapeutic intervention Management Board. (Horatio: European Psychiatric Nurses, 2012). One instance is the Portu† guese case, of where 129/2011 states Health that providing psyPresident ‘The Regulation PortugueseNo Society of Mental Nursing’. chotherapeutic, sociotherapeutic, psychosocial and psychoeducational care is one of the four major specific competences of mental health nurses. However, even in this case, the “Ordem dos Enfermeiros” (the public competent authority, representative of the nursing and midwife© 2015 John Wiley & Sons Ltd ry practice in Portugal), corporate author of that regulation, does not

1,2,3

competence of mental health nurses, who hold the legally required CONCLUSIONS:

with mental and psychological health problems in primary care, counqualification to provide psychotherapeutic interventions. However, in Portuguese patients.

FOR NURSING PRACTICE: study contributed to the selling for lung cancer patients, orThis cognitive–behavioural interventions NOC language and to the enrichment of nursing’s body of knowledge. for elderly depressed people), and, aside from its cost-effectiveness, OBJETIVO: Adaptar a linguagem e avaliar as propriedades psicométricas dos resultados NOC “Nível ansiedade” e “Autocontrolo da ansiedade” em utentes thede results clearly prove its effectiveness—mainly in the short term.6 The discussion on the role of mental health nurses as providers portugueses adultos. In spite of the aforementioned findings, the training of nurses who of psychotherapeutic interventions is not exclusive to the PorMÉTODOS: Estudo metodológico. RESULTADOS: A versão portuguesa do resultado NOC “Nível de ansiedade”, com2,3 put these interventions into practice constitutesinterna. an important issue. tuguese context. Considering the aforementioned, Horatio: Europosta por 16 indicadores, apresentou uma excelente consistência A análise fatorial exploratória (AFE) foi forçada a três dimensões. O resultado NOC “AutoconIndeed, some studies do not present data about the previous training of pean Psychiatric Nurses prepared a position paper on the subject trolo da ansiedade”, composto por nove indicadores, apresentou uma consistência interna A AFEand, foi whenever forçada awe duas dimensões. nurses do find such information, there are clear disand clearly stated that mental health nurses, holding the questionável. appropriCONCLUSÕES: As versões portuguesas dos resultados NOC estudados são inpsicométricas aceitáveis para where avaliarthe a ansiedade parities mostly regarding both the territories intervention ate academic and professional training, are capablestrumentos of providing com psy- propriedades em utentes portugueses. is performed and alsoDE its goals. Hence, it seems to be crucial to clearly chotherapeutic interventions.4 Nevertheless, in some countries (e.g., PARA IMPLICAÇÕES A PRÁTICA ENFERMAGEM: Este estudo contribuiu para o desenvolvimento da linguagem NOC e para enriquecer o corpo de state the difference between a mental health nurse-therapist—a nurse Lithuania, some cantons of Switzerland, Italy, and Russia), nurses are conhecimento de Enfermagem. who undertook specific training in a psychotherapeutic modality— not allowed to perform these same interventions,4 even if there is IMPLICATIONS the Regulation does not state clearly what kind of psychotherapeutic development of

interventions these nurses are allowed to perform.

enough evidence to suggest that no branch of learning proves to ⃝ C

and a mental health nurse—a nurse who may not have undertaken

2017 NANDA International, Inc.

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International Journal of Nursing Knowledge Perspect Psychiatr Care 2017; 00: 1–8

Volume 00, No. 0, January 2017

wileyonlinelibrary.com/journal/ppc

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!jo Francisco Miguel Correia Sampaio | Odete Arau | Carlos Sequeira | Sampaio, F. , Araújo, O., Sequeira, C., Lluch Canut, T., & Martins, T. (2018). Short-term efficacy of a nursing psychotherapeutic intervention for anxiety on adult psychiatric outpatients: A randomised controlled 2096

Journal of Clinical Nursing, 24 , 2096–2105, doi: 10.1111/jocn.12808

7 3,6 Leiria (Portugal). trial. Oral communication presented at 4th International Health Congress “Global Health Trends”, http://dx.doi.org/10.1016/j.apnu.2016.09.007 0883-9417/© 2017 Elsevier Inc. All rights reserved.

REFERENCES Asl, N. H., & Barahmand, U. (2014). Effectiveness of mindfulness-based cognitive therapy for co-morbid depression in drug-dependent males. Archives of Psychiatric Nursing, 28(5), 314–318. http://dx.doi.org/10.1016/j.apnu.2014.05.003 Bulechek, G. M., Butcher, H. K., Dochterman, J. M., & Wagner, C. (2012). Nursing Interventions Classification (NIC) (6th ed.). St. Louis: Elsevier. Cuijpers, P., Sijbrandij, M., Koole, S. L., Andersson, G., Beekman, A. T., & Reynolds, C. F. (2013). The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: A meta-analysis of direct comparisons. World Psychiatry, 12(2), 137-148. http://dx.doi.org/10.1002/wps.20038 Herdman, T. H., & Kamitsuri, S. (Eds.) (2014). NANDA International nursing diagnoses: Definitions & classification, 2015– 2017. Oxford:Wiley-Blackwell. Hyun, M., Chung, H. C., De Gagne, J. C., & Kang, H. S. (2014). The effects of cognitive-behavioral therapy on depression, anger, and self-control for Korean soldiers. Journal of Psychosocial Nursing and Mental Health Services, 52(2), 22–28. http://dx.doi.org/10.3928/02793695-20130930-05 International Council of Nurses (2015). ICNP version 2015 – International Classification for Nursing Practice. Geneva: International Council of Nurses. Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2013). Nursing Outcomes Classification (NOC): Measures of health outcomes (5th ed.). St. Louis: Elsevier. 13


THANK YOU FOR YOUR ATTENTION!

Francisco Sampaio [email protected]

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