Introduction

In Brazil there is a great effort to build a health care model that prioritizes improvement to the quality of life of subjects and the community. In this sense, the federal administration of the Unified Health System (SUS) proposes a transversal, integrated and intersectoral policy that will dialogue with the most diverse areas to promote the quality of life of the population in which all are participants in health care.^(¹) The publication of the National Policy for Health Promotion (PNPS) ratifies the commitment of the Ministry of Health in the expansion and qualification of health promotion actions in the services and in the management of the Unified Health System². For the said Policy, health promotion is a set of strategies and ways of producing health, both individually and collectively, characterized by articulation and cooperation within the sectors and between them, and by the formation of the Health Care Network, seeking to articulate with the other social protection networks to promote a broad participation and a broad social control. Thus, it recognizes other existing policies and technologies aimed at equity and quality of life, reducing vulnerabilities and health risks arising from social, economic, political, cultural and environmental determinants. Thus, objectives, principles, values, guidelines, cross-cutting themes, operational strategies, responsibilities and priority themes aim at equity, improvement of conditions and ways of living and at affirmation of the right to life and health, dialoguing with the reflections of movements in the field of health promotion.²

The importance of the priority themes is well known, as they are evidenced by the health promotion actions carried out since 2006 and inserted in the first version of the PNPS, as well as by the norms and regulations in force at the federal level and by the national and international agreements signed by the Brazilian government, which include permanent education training, adequate and healthy food, corporal practices and physical activities, combating the use of tobacco and its derivatives, combating the abusive use of alcohol and other drugs, promoting safe mobility, promoting peace, human rights and the promotion of sustainable development.² Nurses have taken responsibility for identifying opportunities of health promotion for individuals, families, groups and communities. In this sense, the academic training of nurses in Brazil has been based on the qualification to work in the health promotion. In order to work on the themes listed by the PNPS 2015, it is necessary to know the limits of professional performance, which are determined from the phenomena by which they are clinically and legally responsible. In nursing, in particular, terminologies on nursing diagnoses have been used to provide clear concepts and definitions of nursing phenomena, and can improve care by allowing nurses to use the same language to describe patients’ problems, nursing interventions, and patients’ outcomes in many settings.³

Thus, nurses develop the Nursing Process, which is organized and executed by using the Systematization of Nursing Care (SNC) that guides the activities of the entire nursing team. The SNC has a holistic vision and is composed of interrelated stages, which are history, diagnosis, planning, implementation and evaluation of the nursing results. For the step of identifying the nursing diagnoses, nurses use terminologies that facilitate communication among professionals, among them, the taxonomy proposed by NANDA International (NANDA-I) stands out. The NANDA-I brings a system of classification of nursing diagnoses that enable a standardized language for the practice of nurses. The use of a standardized language is useful to determine more clearly the communication and the care by the nursing team, and allows the creation of protocols to establish priority care for certain populations and to ensure a consistent documentation, representing the professional judgment of clinical nurses. In this way, NANDA-I exists to develop, refine and promote a terminology that reflects the clinical judgments of nurses.⁴

In the said taxonomy, nursing diagnoses constitute a clinical judgment that takes into account human responses to certain health conditions and life processes that may represent a risk to the health of an individual, family, group or community. On the other hand, a health promotion diagnosis is a clinical judgment about the motivation and desire of an individual, family, group or community to increase well-being and accomplish the potential of human health, as manifested in the willingness to improve specific health behaviors.⁴ It is organized into nursing domains, classes, and diagnoses. A domain is a sphere of knowledge, influences and questions. A class is a group, set, or type that shares common attributes.⁵ Domain 1 is the sphere named Health promotion, composed of class 1 that has the ND Deficient diversional activity activity and Sedentary lifestyle, and class 2 has the ND Health control that is composed of the ND Lack of adherence, Risk-prone health behavior, Ineffective health control, Readiness for enhanced health control, Ineffective health maintenance, Ineffective protection, Poor community health, Frail elderly syndrome and Risk for frail elderly syndrome.⁴

It is necessary to recognize the nursing diagnoses associated with the priority themes and, thus, reach objectives proposed by the Ministry of Health to promote health. Therefore, identifying the nursing diagnoses associated with the priority themes of the National Policy for Health Promotion is important because it may facilitate the elaboration of specific nursing care with the aim of expanding health promotion actions. Therefore, the objective of this study is to identify the relationships between nursing diagnoses proposed by NANDA-I and the priority themes advocated by the National Policy for Health Promotion.

Methods

This is a reflexive study carried out from March to July of 2016 based on the critical reading of the PNPS priority themes and the nursing diagnoses (ND) that make up the NANDA-I taxonomy, in order to contextualize these diagnostic labels from the perspective of PNPS. Such methodology resembles qualitative studies, due to the similarity of the form of interpretation and analysis of the scientific findings after literary survey.⁶ An integrative review was made on the study subject because this method contributes to the understanding of a specific problem and provides subsidies for evidence-based practice through informed knowledge.⁷ The search took place in the scientific databases Scopus, CINAHL and SciELO, using the descriptors health promotion, food habits, traffic accidents, drugs abuse, environment and public health, combined through the Boolean operator AND, following the assumptions of the literature review with the objective of gathering studies with focus on the analyzed theme that would support our critical reflection of the findings. Researchers listed those studies characterized as articles, published between the years 2000 and 2016, available in the English, Portuguese or Spanish languages.

Results

The initial sample counted on 908 articles, of which 325 were in the Scielo database, 298 in the CINAHL and 385 in the Scopus. Then, the following inclusion criteria were applied to refine the results: complete and freely available articles in Portuguese, English and Spanish languages that addressed the subject under study. Each article was submitted to reading the title and the abstract to verify the presence of elements that could contribute to the identification of diagnoses related to the Priority Themes. Subsequently, a complete reading of the selected articles was carried out. The final sample consisted of four articles from the SciELO database, three from the CINAHL database and five from the Scopus database. Through the reading of the articles it was possible to identify elements that contributed to the identification of nursing diagnoses present in NANDA-I that could be related to the PNPS priority themes.

PNPS and NANDA-I nursing diagnoses. The PNPS update made it possible to recognize current issues in Brazilian society that need attention from public health policies and other political sectors, as well as the participation of the private sector and the community. The priority themes of the current PNPS are: permanent education and training, adequate and healthy nutrition, corporal practices and physical activity, combating tobacco, alcohol and other drugs, promoting safe mobility, promoting a culture of peace and human rights, and promoting sustainable development.² The relationship between the priority issues of the national policy and the NANDA-I diagnoses are set out in the table below for a better view.

Table 1 The PNPS priority themes and their respective NANDA-I nursing diagnoses. 2016 

Discussion

It is important to emphasize that, although this taxonomy has an exclusive domain for diagnoses of health promotion, it was observed that these are not enough to supply the topics addressed by the current PNPS, therefore, diagnoses of other domains were also listed to compose the findings. The first theme proposed in the document refers to the actions of training managers and health professionals, as well as professionals from other areas, for the development of educational actions in the field of health promotion.² This is in line with that established in article 200 of the Federal Constitution of 1998, which recommends that the Unified Health System is also responsible for the training of health professionals.⁸

The presence of the diagnostic label Deficient knowledge brings attention to the priority theme regarding the qualification of professionals, as well as to the perception of health by individuals and the community. This diagnosis presents as some of its etiological factors the lack of resources for knowledge, cognitive alterations, insufficient information and lack of interest in learning.⁴ The present integrative review brings the manifestation of the nursing diagnosis Deficient knowledge in different scenarios, such as, in the case of puerperal women, in relation to the health care to the newborn and self-care. In this context, the prevalence of this diagnosis was observed in the entire sample studied.⁹ Another study shows the presence of this label in the reality of patients with diabetes mellitus, being prevalent in the majority of the investigated subjects.¹⁰ Regarding the reality of health professionals, the study shows that there is a gap in knowledge regarding exposure to risk agents in the hospital environment. Health professionals have not recognized noise, ionizing radiation, and extreme temperatures as potentially risk factors. In addition, the exposure to physical factors such as humidity, illumination, temperature and radiation was classified as good, which alerts to a misunderstanding about the consequences that such continuous exposure can cause in professionals.¹¹

It is important to highlight that, in addition to the above, permanent education can be linked to validation studies of nursing diagnoses, since there is no specific label for this PT in NANDA-I. Diagnostic validation studies allow the nurse to know about a certain phenomenon of nursing in an accurate way. With this, the professional will be able, through clinical reasoning, to use their learning in clinical practice,¹² improving the care provided, since it reduces bias at the time of diagnostic inference. An inference made without theoretical foundation leads to misconceptions in the planning and execution of nursing care, leading to impairments in the individual's health. Food also enters the list of issues that require greater attention from (federal, state and municipal) managers and health professionals. The current PNPS version highlights the importance of actions aimed at adequate and healthy food to reduce poverty levels.²

The concern with this theme is highlighted in the actions of public policies, evidenced, mainly, in the letters of health promotion. Food is treated as a fundamental factor for the development and growth of the individual, providing the conditions for a satisfactory quality of life. Given such importance, the taxonomy under study encompasses nursing diagnoses focused on the food and nutritional process. NANDA-I brings with it a specific domain for Nutrition, which is defined as "activities of ingesting, assimilating and using nutrients for purposes of tissue maintenance and repairing and energy production”.⁴ This domain is divided into five classes, namely: ingestion, digestion, absorption, metabolism and hydration. However, the diagnostic labels defined so far are concentrated in the classes ingestion, metabolism and hydration.

According to the definition of the PT on feeding, the identified diagnoses that are closely related to this definition were: Ineffective breastfeeding, Insufficient breast milk, Readiness for enhanced breastfeeding, Unbalanced nutrition: less than bodily needs, Obesity, Overweight, Risk for overweight and Readiness for enhanced nutrition. In a study conducted by Teixeira et al.,¹³ the most frequent defining characteristics (DC) of the diagnosis Unbalanced nutrition less than the bodily needs among children in early childhood were: food intake less than the recommended daily portion, irritability, satiety immediately after food intake and lack of interest in food. The prevalence of this diagnosis was estimated by the latent class analysis model in 27.6%. It is important to emphasize that some NANDA-I diagnoses, even belonging to other domains, include nutritional/nutritional aspects as triggers/etiological factors. As an example, there is the nursing phenomenon Frail elderly syndrome, from the Health Promotion domain, which contemplates malnutrition and sarcopenic obesity as related factors for its development.⁴

The third priority content addresses the practice of physical activities, being defined as actions to encourage corporal practice and physical exercises, encompassing improvements in public spaces for such activity.² Within this perspective, the correlated nursing diagnoses were Deficient diversional activity and Sedentary lifestyle, both belonging to the Health promotion domain. Such labels bring as a etiological factor for their manifestation the lack of resources for physical practice, emphasizing the need of spaces accessible to the community for the accomplishment of physical and leisure activities.⁴ The abusive and indiscriminate use of substances harmful to health, such as alcohol, tobacco and illicit drugs, is a current concern in PNPS. Public policies aimed at reducing the consumption of these elements are advocated since the formulation of letters for health promotion. In the current version of PNPS, this theme involves actions of education and health promotion with the objective of reducing and controlling their consumption, counting on educational, economic, legislative and social practices.² This theme can be found in NANDA-I as the diagnosis of the Health promotion domain Risk-prone health behavior, in which the individual manifests incoherent attitudes to lifestyle modification and quality of health⁴, expressed by substance abuse and smoking.

The PT Promotion of culture of peace and human rights aims at articulated actions between the health sector and other social protection networks, with practices that encourage solidarity, coexistence, respect for life and the consolidation of bonds between individuals, in order to reduce violence and promote peace.² Some ND belonging to the Safety/Protection domain alert to the previously mentioned theme. They are: Risk for self-directed and other-directed violence, Self-mutilation and Risk for self-mutilation, and Risk for suicide.⁴ These labels alert to the deficiency present in this issue and corroborates with the current epidemiological data of violence in Brazil. In 2011, Brazil presented rates of 8.6% of SUS hospitalizations related to violence and accidents.¹³ In the previous year, mortality rates related to external causes showed an increase of 8.4% when compared to the year 2001. In addition, the mortality of young people and adolescents due to violence and accidents led the national ranking of death causes,¹⁴ which makes it a public health problem, evidencing the need to implement preventive actions and health promoters.

The Promotion of safe mobility is another evident topic in our society, due to the increase in morbidity and mortality from traffic accidents. This PT corresponds to multidisciplinary and intersectoral actions that include health care from the primary care level to tertiary care. The PNPS emphasizes that investments should be directed towards the educational activities for the promotion of a safe traffic.² Brazilian traffic violence has been an international highlight in recent years, since it has morbidity and mortality rates superior to that seen in the scenarios of military and civil wars. In articulation with the Promotion of culture of peace and human rights, previously mentioned, Brazilian epidemiological data on mortality due to traffic violence, treated with external causes, are alarming. The Mortality Information Subsystem (SIM) presented information on the number of deaths among Brazilian young people in the year 2012. Of the almost 78 thousand deaths in the young population, about 55 thousand were due to external causes, such as violence in traffic. In addition to the young people, there is a high incidence of traffic violence directed at the elderly, considering the vulnerability of this population.¹⁵

Promotion of sustainable development is characterized by the need for actions aimed at taking care of the environment integrated into health actions.² No nursing diagnoses in NANDA-I were identified that included the themes of Promotion of safe mobility and Promotion of sustainable development. Both priority sectors make up a gap within the NANDA-I classification, and they may be suggested for the elaboration of new diagnostic labels, since such approaches characterize the current needs of the context that we are inserted. The environment is seen as all the conditions, circumstances and influences that can affect the development and behavior of the human being. The evolution of the concept of environment according to Roy's Adaptation Model, as well as the individual-environment interaction, becomes an important theme for the understanding of nursing phenomena.¹⁶

Conclusion

Although the NANDA-I taxonomy encompasses about 250 nursing diagnoses, most of these are focused on the individual in a unique way. And although it presents a particular domain for health promotion diagnoses, these were not enough to meet the needs of the priority themes proposed by PNPS. The diagnoses that are most present within the PNPS are those corresponding to the Nutrition domain. It was identified a gap of diagnoses necessary for actions in a collective character regarding environmental, sustainable, educational and safety actions. Based on the findings of this study, it is highlighted the importance of construction of new diagnostic labels in NANDA-I that contemplate the collective needs of the population, as well as to improve the diagnoses belonging to the domain of health promotion.