Translation and cultural adaptation for Brazil of the Developing Nurses' Thinking model.

OBJECTIVES: to translate and culturally adapt to Brazilian Portuguese the Developing Nurses' Thinking model, used as a strategy for teaching clinical reasoning.
METHOD: the translation and cultural adaptation were undertaken through initial translation, synthesis of the translations, back-translation, evaluation by a committee of specialists and a pre-test with 33 undergraduate nursing students.
RESULTS: the stages of initial translation, synthesis of the translations and back-translation were undertaken satisfactorily, small adjustments being needed. In the evaluation of the translated version by the committee of specialists, all the items obtained agreement over 80% in the first round of evaluation and in the pre-test with the students, so the model was shown to be fit for purpose.
CONCLUSION: the use of the model as a complementary strategy in the teaching of diagnostic reasoning is recommended, with a view to the training of nurses who are more aware regarding the diagnostic task and the importance of patient safety.

Introduction

Patient safety in health care has mobilized global efforts(. In this scenario, nursing professionals have the potential for a great impact for the achieving of health care which is safe, high quality and efficient(.

The accurate interpretation of human responses, an activity for which the nurse is responsible, is a complex task and directly affects the quality of the health care given to the patient. If the nurse's interpretations of the human responses do not correspond to the patient's experiences, these interpretations, due to not being sufficiently accurate, will not guide the selection of appropriate interventions(.

In Brazil, resolution 358/2009( of the Federal Council of Nursing regulates that the nursing process should be undertaken in all the environments in which nursing care takes place, leadership in carrying out and evaluating this process falling to the nurse. Emphasis is placed on the importance in the nurse's training regarding accuracy in the stages of the nursing process and their documentation(, given that valid and reliable documentation is an important element for safety and quality of health care.

The relevancy of critical thinking in nursing has been emphasized in response to the rapid change of the health care environment. Nurses need to think critically in order to provide care which meets the patient's needs and which allows them to deal with the complexity of the health system(.

Critical thinking involves skills and attitudes which are necessary for the development of clinical reasoning, which is based on existing knowledge and the context in which the experiences of interpreting observable data occur. Clinical reasoning, in its turn, refers to the mental processes involved in health care, and is present in the nurse's actions and assistential decisions(.

The educational model Developing Nurses' Thinking (DNT)(, developed by a North-American researcher with a view to the training of nurses capable of making accurate interpretations in the various decisions involved in the nursing process, proposed to lead the student in the process of clinical reasoning. In the DNT model, four components (patient safety, domain knowledge, nursing-specific critical thinking processes and repeated practice) are integrated, to guide the student to organize thinking processes, interpret patient data, name the interpretation of data, and develop care plans. The model's theoretical basis is grounded in the triarchic theory of human intelligence(.

The DNT model's author, in a quasi-experimental study(, demonstrated that its use in teaching clinical reasoning can improve the accuracy of the interpretations made by the students when they elaborate nursing diagnoses.

Considering that the teaching of clinical reasoning is one of the factors associated with the accuracy with which the nurses establish nursing diagnoses(, having models and strategies for this teaching available is fundamental to the training of professionals who are capable of offering quality, person-centered care. This article is a report of the study in which the DNT model was translated and culturally adapted for Brazilian Portuguese.

Method

The aim of the cultural adaptation is to maintain the validity of the instrument's original content but adapted to different cultures(. The translation and cultural adaptation of the Developing Nurses' Thinking (DNT) model followed the guidelines of the American Academy of Orthopedic Surgeons (AAOS)(, the intention being to keep the integrity of the model's original content. The choice of the AAOS methodology was motivated by the rigor required to ensure that the validity of the material's content in the culture of origin would be maintained in the target culture.

The AAOS guidelines present a methodology for the translation and cultural adaptation of measuring instruments. This methodology was constructed and structured based on a systematic review study of the method and its refining by specialists(. Thus, the present study follows the stages of initial translation, synthesis of translations, back-translation, evaluation by a committee of specialists, and pre-testing, in line with the AAOS guidelines.

The three environments of the theory of triarchic intelligence( are pre-suppositions of the DNT model; hence, it is considered that intelligence develops in: the internal environment, in which the domain of knowledge is attained and the processes of critical thinking occur; the external environment, in which a given context, such as that of patient safety, is considered; and the effect of the experience, which is achieved through repeated practice of using the processes of thinking with the domain of knowledge.

The DNT model is based on four components(: patient safety, domain knowledge, critical thinking and repeated practice. The component of patient safety refers to the patient being free from accidental injury(. The component of domain knowledge consists of the knowledge which the nurse uses in interpreting the patient's data in order to resolve health problems. The domain of knowledge, which is used by student nurses, is derived from the sciences and the humanities and includes the physiopathology of diseases, patients' possible responses to the disease, nursing diagnoses from the NANDA International terminology( and possible treatment options for efficient care plans. The component of critical thinking in nursing is characterized by the mental processes used by the nurses in order to resolve problems from the specific domain of nursing(. The component of repeated practice is considered to be the repetition of a process two or more times(. These components are presented to the students in the form of tables and diagrams, helping in the analysis of clinical cases.

The five stages covered in the process of the cultural adaptation of the DNT model are described below.

In the stage of initial translation, two translations into Portuguese were made of the DNT model (T1 and T2). These were made independently, by Brazilian individuals, with extremely good English and who had lived in English-speaking countries. The first translator (T1) invited to participate was a specialist on the issue and the second (T2) was a professional translator with no specific knowledge in the area. In order to reconcile the two translations, two of the researchers involved independently analyzed the translations T1 and T2 compared with the original version and, following that, in an in-person meeting, defined the synthesis of the translations by mutual agreement (T12).

The back-translation, the translation of the model back into the language of origin, was undertaken by two translators born and educated in English-speaking countries, but who live in Brazil, who know the linguistic and cultural properties of Brazil but who were not familiar with the material to be translated.

The translators received the synthesized version of the translations (T12), in Portuguese, and translated the instrument to its original language (English), creating two versions (BT1 and BT2). The back-translation versions (BT1 and BT2) were sent to the author of the DNT model for evaluation, so that possible changes in the original content, arising from the translation process, could be identified.

In the next stage, the translated version (T12) was submitted for analysis by a committee made up of: a specialist in nursing diagnosis (professor and researcher), a methodologist (researcher with scientific articles published on cultural adaptation), a person with a PhD in linguistics, two researchers from the study which monitored the translation process and one student from the undergraduate nursing course. The student was included in the committee as a representative of the target public of the DNT model.

The translated version (T12) and the instructions for individual evaluation were passed to the members of the committee, through a questionnaire with 22 items in the terms of which the DNT model was to be evaluated. For the translation and adaptation to be considered accepted, a minimum of 80% of the committee members had to judge each characteristic of the DNT model as adequate.

The committee of specialists judged the adequacy and clarity of the vocabulary and expressions used in the translated version of the DNT model and, for the equivalences: semantics, referring to the meaning of the word; idiomatic, referring to the use of expressions in the respective languages, in the case of colloquial expressions of the original language; cultural, referring to the terms, expressions and routine situations which may potentially differ between the countries' cultures; and conceptual, referring to the item's coherence in relation to the domain to which it belongs.

In the pre-test, the last stage of the process of cultural adaptation, the final version of the DNT model was applied to 33 undergraduate nursing students, this group being predominantly made up of female students (94%), with a mean age of 22 years old (SD±3.0) who were in the second year of the undergraduate nursing course (94%). The purpose of the model and the research were explained to the students, and they were informed that they were to express their opinion regarding their understanding of the meaning of the items and the items' clarity.

Initially, the students participated in an hour-long lecture in which the issue of clinical reasoning was discussed and the DNT model's theoretical frameworks, components and conceptual framework were presented. Following that, the students used the model - already implemented in educational software( - to analyze a clinical case.

The research was approved by the institution's Research Ethics Committee (process 778/2010) and was undertaken in conformity with Resolution 196/96 of the National Health Council. All the participants signed the terms of Free and Informed Consent and the author of the DNT model granted authorization for the adaptation.

Results

The DNT model was translated to Brazilian Portuguese and integrated into the second version of an educational software(. The process of translation and cultural adaptation lasted six months and involved the support of the model's author.

The two versions of the initial translation of the DNT model (T1 and T2) arrived at similar results, few adjustments being necessary in the consensus meeting between the researchers for achieving the synthesis of the translations (T12). The two versions of the back-translation (BT1 and BT2) were sent to the model's author, who checked the validity for both versions, and indicated that they were highly similar to the original content. From this result it was taken that the Portuguese version (T12) was appropriate for submitting to the committee of specialists for consideration. These judged the translation to be adequate according to the 22 items evaluated, with agreement over 80% in the first round of evaluation.

In the pre-test, the students had no difficulty in understanding the meaning and clarity of the model's items.

The instruments which make up the DNT model, translated and adapted to the Brazilian culture, are presented below. In the model's conceptual framework (Figure 1) the four components upon which it is based are integrated: patient safety, domain knowledge, critical thinking processes and repeated practice.

Figure 1

Conceptual framework of the Developing Nurses' Thinking model, culturally adapted for Brazil

The seven skills of critical thinking and the ten habits of the mind( are broken down and presented in the form of a table (Figure 2), with the aim of being a strategy for helping the student in the analysis of clinical cases. The field "patient data and results of the evaluation" is designated for the description of the clinical case to be analyzed by the student. The component "patient safety" is set out in the lower part of the table, reminding the student that this underlies the entire process of care.

Figure 2

The Developing Nurses' Thinking model, adapted culturally for Brazil

Habilidades de pensamento crítico	Dados do paciente e resultados da avaliação	Hábitos da mente
Análise		Confiança
- Divida a apresentação/questão em partes (pistas) para determinar o significado (ou seja, normal vs anormal)		Você está confiante em suas habilidades de raciocínio?
Identifique pistas		Perspectiva contextual
- Agrupe as pistas para determinar o significado		Você considerou todo o contexto deste problema? Idade, comorbidades, medicações etc.
- Gere hipóteses		Criatividade
Aplicação de padrões		Você foi criativo ao gerar ou reestruturar ideias?
- Use padrões/regras baseados em pesquisa para incluir ou descartar hipóteses		Você pensou em alternativas?
- Características definidoras de Diagnósticos de Enfermagem, fatores relacionados e situações de risco; fisiopatologia		Flexibilidade
- Faça um julgamento que "se encaixe"		Você considerou múltiplas possibilidades? Você ficou restrito a uma linha de pensamento?
Discriminação		Curiosidade
- Procure por diferenças e semelhanças		Você estava ansioso para interpretar corretamente a situação/ problema e usou observação e questionamento reflexivo para explorar possibilidades?
- Isso ajuda a confirmar ou desconfirmar hipóteses?		Integridade intelectual
Busca de informação		- Você usou processos baseados em pesquisa e critérios baseados em pesquisa para interpretar a situação/problema?
- Você precisa de mais informação para resolver este problema? Informação do paciente/ subjetiva ou objetiva? Dados laboratoriais? Avaliação física adicional?		- "Chutar" sem uma base da qual extrair significado não conta
Raciocínio lógico		Intuição: reconhecimento de padrão
- Tire conclusões		Você reconheceu qualquer coisa que lhe pareceu familiar a partir de experiências anteriores?
- Se isso, então provavelmente aquilo		Mente aberta
- Confirme ou desconfirme o diagnóstico		Você estava aberto a outras possíveis interpretações da situação/dados?
Predição
- Prediga os problemas potenciais do paciente e visualize um plano & resultados desejados		Perseverança
- Como esse problema/plano afetará a segurança do paciente? Se eu fizer isso então...		Você estava determinado a interpretar acuradamente a situação/problema?
Transformação do conhecimento		Reflexão
- Como você reconhecerá esse mesmo conceito/problema em outras situações?		Você refletiu constantemente sobre o seu pensamento, pressupostos e decisões para assegurar uma interpretação acurada dos dados?
Segurança do paciente

A form for problems (Figure 3) is presented to the student with fields for the student to describe the problems she finds in the analysis of the clinical case, to validate the information, to reconsider the component "patient safety", to plan the results she wishes to achieve, and the interventions, and to undertake the final evaluation of the process.

Figure 3

Form for problems of the Developing Nurses' Thinking Model, culturally adapted for Brazil

Formulário de problemas: esses podem ser diagnósticos de enfermagem, possíveis problemas médicos ou a descrição do problema
Problema	Confirmação	Desconfirmação	Este problema afeta a segurança do paciente? Se sim, como?	Resultados esperados	Intervenções/ avaliação
	Características definidoras	Características
	Achados da avaliação que apoiam a identificação do problema (isso inclui fatores relacionados & aqueles que colocam o paciente em risco para problemas)	Achados da avaliação que NÃO apoiam a escolha desse problema
1.
2.

Discussion

The use of the DNT model in teaching aims to lead the student to develop habits of thinking and to improve her diagnostic accuracy, questions which impact directly on the patient's results and on the safety of the health care. This strategy can be used in the analysis of clinical cases, a stage in which the DNT model was used in the second version of an educational software(, a teaching tool which evaluates diagnostic accuracy.

The DNT model's conceptual framework (Figure 1) offers the student understanding in relation to the stages of the nursing process, which are permeated by the skills of critical thinking and the habits of the mind, related to the context of the patient's safety. In this strategy, the student is caused to reflect on each stage of the nursing process; to consider which skills of critical thinking and/or habits of the mind are used in each stage of the process; and to evaluate whether the patient's safety was taken into account. This approach seeks to stimulate the student's metacognition, guiding her reflection on decision-making in the nursing process in the internal environment (processes of thought).

It is proposed that the student makes use of the model (Figure 2) in the analysis of clinical cases, which favors the use of the skills of critical thinking and of the habits of the mind. The route presented in the DNT model guides the student to the understanding of the aspects which must be considered in the analysis of a clinical case, raising her chances of achieving an accurate diagnosis. The nursing student with little clinical experience can use the model to understand how nurses think. As she becomes more experienced in the diagnostic task, the student develops and strengthens the skills of critical thinking and the habits of the mind in her clinical practice.

Making use of the form for problems (Figure 3) the student is guided to list the problems raised in the clinical case analyzed. Once these problems have been identified, the student describes the findings which support the problem raised, that is, the defining characteristics, risk factors and related factors. In the item "disconfirmation" the student is invited to rethink regarding the clinical case and to identify the presence of possible cues which do not support the choice of the problem raised. Following that, the student is directed to reflect on the possible impact of the problem identified for the patient's safety, and the possible consequences if it is not treated. The results expected, and the nursing interventions, are also listed in the table, as well as the evaluation of the process. By presenting the patient's safety in the first instance of consideration, the DNT model helps the student to prioritize it.

Given that one of the predictive factors of nurses' diagnostic accuracy is the teaching of theoretical and practical content on nursing diagnoses in the undergraduate course(, the use of the DNT model in teaching is a strategy for training nurses who are aware regarding the diagnostic task and the nursing process in clinical practice.

The DNT model satisfies the needs indicated in the literature regarding the development of innovations to improve the preparation of nursing students for clinical practice(, as well as of tools which support the student in the improvement of clinical reasoning skills and reflection on practice(.

The study's limitations include: (a) it was not possible to include the translators who participated in the processes of translation and back-translation in the committee of specialists; (b) the form for problems (Figure 3) was not evaluated in the pre-test stage, because of not having been implemented in the software used by the students.

The use of the DNT model is recommended as a strategy of support for the teaching of diagnostic reasoning, with a view to the training of nurses who are more aware regarding the diagnostic task and who are capable of prioritizing the aspect of the safety of the care.

One of this study's implications for research is that the effectiveness of the DNT model for elaborating accurate diagnoses must be tested through comparing it with the usual practices of the teaching of clinical reasoning. In the ambit of the care, the model can be tested in continuous education programs and also for the analysis of especially complex situations in usual clinical practice.

Conclusion

The undertaking of this study allowed the Developing Nurses' Thinking model, its conceptual framework and form for problems - used by the student in analyzing clinical cases - to become available for use in Brazil.

It is considered that the methodology used in this study, the guidelines of the American Academy of Orthopedic Surgeons, was sufficiently and methodologically rigorous to achieve the translation and cultural adaptation of the DNT model. There were no difficulties during the study in relation to the methodology adopted.

The DNT model, adapted for use in Brazil, is a feasible strategy for teaching clinical reasoning, which allows one to integrate the perspective of patient safety with the skills of thinking and the habits of the mind.

Erratum

Issue v22n2, page 197

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Translation and cultural adaptation for Brazil of the Developing Nurses’ Thinking model1

1 Paper extracted from doctoral dissertation "Evaluation of the Fuzzy Kitten software as a methodology for teaching diagnostic reasoning in nursing", presented to Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil. Supported by Fundo de Apoio ao Ensino, à Pesquisa e à Extensão (FAEPEX).

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Translation and cultural adaptation for Brazil of the Developing Nurses’ Thinking model1

1 Paper extracted from doctoral dissertation "Evaluation of the Fuzzy Kitten software as a methodology for teaching diagnostic reasoning in nursing", presented to Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil. Supported by Fundo de Apoio ao Ensino, à Pesquisa e à Extensão (FAEPEX) and by Fundação de Amparo à Pesquisa do Estado de São Paulo, process # 2010/10158-2.