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International Journal of Nursing Studies 46 (2009) 189–196

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The association between nursing diagnoses,

resource utilisation and patient and caregiver outcomes
in a nurse-led home care service:
Longitudinal study
J.M. Morales-Asencio a,*, J.C. Morilla-Herrera a,b, F.J. Martı́n-Santos a,c,
E. Gonzalo-Jiménez a, M. Cuevas-Fernández-Gallego a,d, C. Bonill de las Nieves e,
A. Tobı́as-Manzano f, A. Rivas-Campos g
a
Andalusian School of Public Health, Granada, Spain
b
Nursing Homes Unit, Primary Health Care District, Málaga, Spain
c
Nursing Services, Primary Health Care Distrito, Málaga, Spain
d
Primary Health Care District, Málaga, Spain
e
Research Unit, Primary Health Care District, Málaga, Spain
f
Primary Health Care District, Almerı́a, Spain
g
Primary Health Care District, Granada, Spain
Received 23 February 2008; received in revised form 14 September 2008; accepted 20 September 2008

Abstract

Background: The information generated by nurses through standardised nursing languages is insufficiently evaluated and
exploited, mainly in home care services, as is its potential impact on outcomes.
Objectives: To find out how often nursing diagnoses are made during nursing home care visits, and to explore their relation with
use of resources, mortality, institutionalisation and satisfaction.
Design: Observational, longitudinal follow-up study.
Settings: Home care services delivered by Primary Healthcare Districts in Málaga, Costa del Sol, Almerı́a and Granada, in
Spain.
Participants: Patients and caregivers who initiated the Home Care Programme.
Methods: The accumulated incidence of nursing diagnosis was analysed over 34 months of follow-up. Diagnoses were made by
nurse case managers in their daily practice. Several regression models were devised to analyse their linkage with the use of
resources, mortality, institutionalisation and satisfaction.
Results: Two hundred and forty-seven subjects were included (129 patients and 118 caregivers). 93.8 had been diagnosed (2.8
diagnoses per subject). Risk of caregiver strain and mobility impairment accounted for 40% of total home visits ( p = 0.033).
Significant differences were observed in the use of physiotherapy and rehabilitation services. The home visits for caregivers
were, in 78% of cases, due to the recipient’s baseline functional status. No relation was detected for institutionalisation or for
patient satisfaction. There was a higher rate of anxiety diagnosed in the caregiver when the recipient was at greater risk for
mortality (RR: 2.08 CI 95%: 1.26–3.42) ( p = 0.012).

* Corresponding author at: Escuela Andaluza de Salud Pública, Cuesta del Observatorio s/n, 18080 Granada, Spain.
E-mail addresses: josem.morales.easp@juntadeandalucia.es, jmmasen@gmail.com (J.M. Morales-Asencio).

0020-7489/$ – see front matter # 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2008.09.011
190 J.M. Morales-Asencio et al. / International Journal of Nursing Studies 46 (2009) 189–196
Conclusions: These data confirm results from other studies which find nursing diagnoses to be sound predictors of resources
use. Their synergy with other case-mix systems in home care should be investigated.
# 2008 Elsevier Ltd. All rights reserved.
Keywords: Nursing diagnosis; Home care services; Caregivers; Long-term care
What is already known about the topic?
 Nursing diagnoses have been suggested as predictors of
resource utilisation in different settings, mainly in hospitals.
 The utilisation of nursing care plans and nursing diagnosis
has been reported to have a positive influence on the
quality of assessments and registration.
What this paper adds
 This study shows how certain nursing diagnoses can be
related to the use of home care services.
 No relation was found to exist with satisfaction or insti-
tutionalisation.
 We found an association between patient mortality and
anxiety in the caregiver.
1. Introduction
Nursing has made a difference in the conceptualisation of
care over the last three decades, with special emphasis on the
development of standardised nursing language systems
(SNLS), which provide a description of nursing phenomena
concerning individuals, families or communities (NANDA,
2003), as well as the interventions applied by nurses (Nur-
sing Intervention Classification, NIC) (McCloskey and
Bulechek, 2000) and outcomes achieved (Nursing Outcomes
Classification, NOC) (Johnson et al., 2000).
The potential impact of nursing diagnosis on patient out-
comes, above all, hospitalised patients, has been examined in
different contexts and ways since the last century. Most of these
have been reports on the impact on length of stay, mortality,
morbidity, economic outcomes, or improvements to the expla-
natory power of traditional case-mix systems based on medical
diagnosis (Halloran, 1985; Rosenthal et al., 1992; Ferrús et al.,
2001; Welton and Halloran, 2005). Other important approach
has been the analysis of SNLS implementation and their
potential impact on nurses and hospital performance (Currell
and Urquhart, 2003; Müller-Staub et al., 2006).
Specifically, in nursing home care services, Marek (1996)
and Coenen et al. (1996) found that variations in the
frequency of home visits and time spent on care could be
better explained by nursing diagnosis (through the Omaha
System) than by medical diagnosis or demographic data.
The results of research on frequency of nursing diagnosis
in home care have been highly variable, due to the hetero-
geneity of contexts, populations and methods used. The most
widely recorded diagnoses are mobility impairment, with a
prevalence of 73–74.9% (Glick, 1994; Nieto et al., 2004);
risk of injury (51.8%); caregiver role burden (39.5%); and
urinary incontinence (49%) (Ponce et al., 2006).
Beyond the epidemiological description of nursing diag-
nosis, in studies designed to highlight the association of
nursing diagnoses with home care utilisation, Lee and Mills
(2000) analysed the Minimum Data Set from a home care
service and identified six nursing diagnoses correlated with
home visits (13.98 per patient), where mobility impairment
and cognitive deficit were evident. In their study, only three
medical diagnoses were significantly related to the use of
home care resources.
In Spain, del Pino et al. (2001) obtained similar results
although this was not in the home care setting, but in a
Health Centre with a chronically ill population. Their data
suggest that the burden of visitation was justified in 58.5%
according to the nursing diagnoses, vs. 4.42% in the case of
medical diagnoses.
Since 2002, our research team has been studying the
effectiveness of home care services and over 4 years we have
conducted a multicentre, quasi-experimental study to eval-
uate the effectiveness of a new home care model, with the
incorporation of nurse case managers, together with other
interventions (i.e. home physiotherapy services, technical
aids, etc.) in the Andalusian Healthcare Service (ENMAD
study). These results are to be published elsewhere (Mor-
ales-Asencio et al., 2008).
In the course of this experimental study, since nurses used
nursing diagnoses in their daily practice, we decided to
explore their potential relation to home care utilisation,
among others.
The aims of the study were:
a. To identify the frequency of nursing diagnosis in home
care through this new model, which added case manage-
ment services.
b. To determine the relationship between nursing diagnosis
and the utilisation of home care services.
c. To determine the relationship between nursing diagnoses
and mortality, institutionalisation and satisfaction with care.
2. Materials and methods
As above mentioned, this study was developed as a
nested substudy from an overall study that was devised as
a multicentre, quasi-experimental study with a concurrent
 J.M. Morales-Asencio et al. / International Journal of Nursing Studies 46 (2009) 189–196
control group. The nested substudy involves an observa-
tional, longitudinal prospective cohort study with subjects
drawn from the intervention group of the main study. So as to
avoid the Hawthorne effect in the overall study, data collec-
tion of main outcomes in the control group was undertaken
through telephone surveys, thus preventing diagnostic jud-
gements. The subjects in the study were patients and care-
givers who needed home-based care and were included in
home care programmes.
The inclusion criteria study were: new patients or care-
givers who were suitable candidates for one of the home care
services, i.e. individuals who were disabled, terminally ill,
discharged from hospital and primary caregivers. The exclu-
sion criteria included: (a) institutionalisation, and lost to
follow-up, (b) change of residence, (c) hospitalisation longer
than 1 week (when patients were admitted for over 7 days,
providing they met the remaining criteria, were considered
as a new case. We wanted to avoid bias as hospital stay
substantially modifies care needs in vulnerable populations).
The study recruitment area included Primary Healthcare
Districts in Malaga, Costa del Sol, Almeria and Granada.
Based on the criteria for estimation used in the Service
Portfolio of the Andalusian Health Services, the eligible
population involved 45,717 subjects (18,913 mobility-
impaired, 2066 terminally ill, 4587 hospital discharges,
and 20,151 caregivers). A population sample of 105 subjects
with a replacement rate of 30% was needed to detect a
frequency in the most common diagnosis (impairment in
mobility) in over 74% of this reference population—accept-
ing an alpha risk of 0.05 and an accuracy of 10% in a
bilateral contrast. The subjects were chosen through strati-
fied, systematic, non-random sampling via proportional
allocation by Healthcare Districts (first level), by Health
Centres (second level) and by a home care group (third
level). The general ENMAD study identified a total sample
of 647 subjects. The sub-sample from the intervention group
for the present study comprised a total of 312 subjects, which
amply met our requirements.
The following follow-up periods were established, in line
with the characteristics of the population:
 Terminally ill individuals: until the time of death
 Individuals with impaired mobility
 Discharges: up to 2 months
The variables studied were:
 Characterisation of the sample: age, sex, patient–care-
giver relationship, hours spent caring for the family, home
programme to which they individual was assigned based
on the Service Portfolio of the Andalusian Health Services
 Mortality
 Institutionalisation
 Comprehensive assessment of the patient: functionality
(Barthel and Lawton-Brody), cognitive status (Pfeiffer)
 Family function: family APGAR
191
 Caregiver overload: Zarit test
 Satisfaction: SATISFAD# (Morales-Asencio et al., 2007)
 Patient’s nursing diagnoses
 Caregiver’s nursing diagnoses Criteria of the results NOC:
2202 (preparation of family caregiver), 2210 (family
caregiver strength), 2605 (family involvement), 1813
(knowledge of therapeutic regimen), 1806: (familiarity
with resources)
 Use of health care services: number of nurses’ visits to the
home, number of patient and caregiver visits to the health
centre, degree of social assistance provided, number of
physiotherapy sessions, number of visits from other pro-
viders (the social worker, the rehabilitation specialist, and
the occupational therapist), as well as the number of
contacts with other professionals, number of visits to
the Accident & Emergency Department, and number of
hospital readmissions.
Clinical data was compiled directly by the nurse case
managers in the course of their usual clinical practice,
prospectively. The data on frequency of visits and use of
healthcare services were gathered retrospectively via elec-
tronic clinical records.
All patients were asked for their consent to participate in
the study and, in cases of cognitive impairment, consent was
requested from the primary caregiver.
The data base storage system was designed with File-
maker Pro 5.0 software. For statistical analysis, the data were
exported to the SPSS 13.0 statistical analysis package.
Clinical and personal data were kept separate at all times
by using alphanumerical codes.
Since these were new cases for home care and nursing
diagnoses were made as events occurred, we were able to
analyse the incidence accumulated over the 34-month study
period (November 2003–September 2006). Descriptive sta-
tistics were used to examine the results with measures of
central trends and scattering, as well as percentage calcula-
tions for qualitative variables. Using exploratory analysis,
the normality of distributions was verified using the Kolmo-
gorov–Smirnov and the Shapiro–Wilk tests. Tukey transfor-
mations were performed in those cases with excessively
asymmetrical distribution.
Bivariate analysis via Student’s T distribution was per-
formed for independent samples in quantitative variables
with a normal distribution and via Mann–Whitney’s U-test
when this condition was not met. The Chi-square test was
used for qualitative variables.
Finally, several multiple regression models, both linear
and logistic, were constructed in order to determine the
relation between variables.
3. Results
A total of 312 subjects were included, with a sample loss
of 20.85% (70.76% due to death, 6.15%, institutionalisation
192 J.M. Morales-Asencio et al. / International Journal of Nursing Studies 46 (2009) 189–196

and lost to follow-up, 4.61%, change of residence, 15.38%, Table 1

hospital admission, 1.53%, refusal to participate). This left a Patients and caregivers characteristics.
final total of 247 subjects (129 patients and 118 caregivers) Patients (n = 129) Mean (DS)
(Fig. 1). or n/N (%)
Sample characteristics are detailed in Table 1. Patients Age 75.49 (13.13)
were distributed in categories of mobility-impaired Female 75/129 (58.0)
(n = 74; 57.4%), terminally ill (n = 13; 10.1%) and hospital Length of home care service 312.03 (301.48)
discharges (n = 42; 32.6%); this highlighted both the APGAR (family functioning) 8.30 (2.17)
elderly age of the patients and the considerable amount Barthel Index (functional status) 44.14 (28.96)
of time caregivers devoted to caring for their loved one. Pfeiffer (cognitive function) 3.22 (3.47)
Likewise, patient dependence was high, as was mean Lawton-Brody (Instrumental 1.42 (1.59)
functional status)
caregiver overload.
93.8% of the patients had identified nursing diagnoses,
Caregivers (n = 118) Mean (S.D.)
with an average of 2.8 diagnoses per patient during the study or n/N (%)
period.
The mean duration of home care during the study period Age 57.24 (13.31)
Female 101/118 (85.6)
was 492.68 days (CI 95%: 446.06–539.30). Clearly, the
More than 20 h/day dedicated 44/118 (37.3)
mobility-impaired group had a longer duration (522.68 days, to delivering care
CI 95%: 450.03–595.33), along with the caregivers (679.83 Relationshipo: spouse 38/118 (32.2)
days, CI 95%: 621.83–737.83). The shortest home care Relationship: son/daughter 61/118 (51.7)
period was for terminally ill patients (137.69 days, CI Zarit (caregiver burden) 57.37 (15.23)
95%: 91.73–183.65) and hospital discharges (65.07 days; APGAR (0–10). Scores: 7–10: normal/3–6: moderate disfunction/
CI 95%: 61.00–69.14). <3: severe disfunction.
Barthel (0–100). Scores: 0–20 full dependency/21–60 severe depen-
3.1. Frequency of nursing diagnoses dency/61–90 moderate dependency/91–99 slight dependency/100
independency.
Table 2 provides details of distribution of nursing diag- Lawton-Brody (0–8). Scores: 8: high/0: low.
noses. It can clearly be seen how the majority of diagnoses Pfeiffer (0–10). Scores: risk of cognitive impairment from 3 points.
detected by the nurses occur in situations of high levels of Zarit (22–110): scores: 22–46: no burden, 47–55: slight burden, 56–
110: high burden.
dependency.
Subgroup analysis showed the clearest profile of care
substitution for mobility-impaired patients where there were as well as body image disorder. In patients discharged from
multiple diagnoses of inability for self-care. In terminal hospital and requiring home care, diagnoses, such as anxiety,
patients, however, the pattern of nursing diagnoses was acute pain as well as the risk of infection was reported. With
different with records of pain and anxiety regarding death, regards to the caregivers, the causative factors for nursing

Fig. 1. Flow diagram of participants.

 J.M. Morales-Asencio et al. / International Journal of Nursing Studies 46 (2009) 189–196 193

Table 2 Table 3
Frequency of nursing diagnosis in patients (n = 129). Frequency of diagnosis in caregivers.
n (%) n (%)
Mobility impairment 53 41.09 Anxiety 18 15.25
Risk for falls 37 28.68 Risk for caregiver role strain 12 10.17
Self-care deficit: bathing/hygiene 34 26.36 Caregiver role strain 10 8.47
Risk for skin integrity impairment 31 24.03 Health seeking behaviours 8 6.78
Self-care deficit: dressing 24 18.60 Knowledge deficit 6 5.08
Urinary incontinence 18 13.95 Urinary incontinence 5 4.24
Skin Integrity Impairment 16 12.40 Sleep pattern disturbance 4 3.39
Self-care Deficit: feeding 15 11.63 Ineffective coping 3 2.54
Self-care deficit: toileting 14 10.85 Dysfunctional grieving 3 2.54
Activity intolerance 12 9.30 Family processes: disruption 3 2.54
Risk for fluid volume imbalance 7 5.43 Ineffective family coping: compromised 3 2.54
Ineffective coping 7 5.43 Noncompliance 2 1.69
Anxiety 7 5.43 Constipation 2 1.69
Pain 7 5.43 Ineffective management of therapeutic regimen 2 1.69
Risk for infection 7 5.43 Pain 2 1.69
Risk for disuse dyndrome 6 4.65 Altered nutrition: risk for more than 2 1.69
Ineffective management of 6 4.65 body requirements
therapeutic regimen Others 5 5.95
Memory impairment 6 4.65
Total 92 77.94a
Constipation 5 3.88
a
Verbal communication impairment 5 3.88 Percentage over the subjects (one patient can present more than
Leisure activities deficit 4 3.10 one diagnoses).
Risk for low situational self-esteem 3 2.33
Others 17 13.17
used as predictors and number of nurses home visits as
Total 341 264.35a
dependent variable. The final model obtained (Table 4)
a
Percentage over the subjects (one patient can present more than showed an explanatory capacity for about 40% of the visits
one diagnoses). ( p = 0.033), with the risk of strain in the role of caregiver
being the only diagnosis that contributed significantly to this
diagnoses are detailed in Table 3. Some diagnosis was positive relation (beta coefficient 0.548, CI 95%: 0.127–
present in 42.4% of caregivers. 0.668; p = 0.005). This was followed closely by deteriora-
tion in physical mobility, although this was not statistically
3.2. Use of services and nursing diagnoses significant ( p = 0.076). Age, functional or cognitive status
did not influence the number of visits (previously, in earlier
Several stepwise regression models were devised to regressions steps, age and sex of the caregiver was rejected
determine the explanatory factors for the use of home care as these made no contribution).
visits. For this purpose, blocks corresponding to nursing A composite variable was constructed that represented
diagnoses and outcomes (NOCs and nursing diagnoses of the the patients with problems of autonomy in order to meet
patient and the caregiver), as well as variables characterising some of their most basic needs (self-feeding and drinking,
the sample (age, sex, functionality and cognitive state) were moving, self-care and hygiene, dressing and grooming).

Table 4
Home care utilisation and nursing diagnoses for all subjects.
Dependent variable: home visits Sig.
2
R = 0.636 R = 0.404 0.033

Model Stand coeff. (beta) Sig. CI 95%

Low High
(Constant) 0.000 0.530 1.268
Risk for falls 0.086 0.620 0.203 0.333
Mobility impairment S0.335 0.076 0.486 0.026
Risk for caregiver role strain 0.548 0.005 0.127 0.668
NOC 2605 family participation in professional care 0.144 0.452 0.033 0.015
NOC 2210 caregiving endurance potential 0.063 0.717 0.029 0.020
194 J.M. Morales-Asencio et al. / International Journal of Nursing Studies 46 (2009) 189–196
Significant differences were observed in physiotherapy and
rehabilitation mean of interventions, that benefited those
patients with a greater loss of independence: 3.60 (CI 95%:
1.35–4.88) vs. 10.80 (CI 95%: 6.56–15.04), p = 0.04, respec-
tively. Inversely, caregivers of these patients had a mean of
visits to Health Centre lower than those who were more able
to cover their own basic needs: 9.93 (CI 95%: 6.29–13.57)
vs. 6.21 (CI 95%: 3.70–8.74), p = 0.006.
In addition, a regression model was devised in order to
ascertain the influence of nursing diagnoses for caregivers on
the number of visits. The result from stepwise forward
regression using the risk of caregiver strain, baseline func-
tionality and patient age as predictors and number of nurse
home visits as dependent, showed that patient baseline
functionality accounted for 78% of the home visits for
caregivers included in the services portfolio (beta coefficient
for Barthel Index: 0.020, CI 95%: 0.031 to 0.008;
p = 0.009), but not the risk of caregiver strain.
3.3. Nursing diagnoses, mortality and
institutionalisation
With regards to institutionalisation, no association was
found between the presence of diagnoses, such as impaired
mobility, deterioration in skin integrity, the risk of falls,
caregiver anxiety or strain in the caregiver role.
However, a significant association was seen between the
presence of caregiver anxiety and patient mortality (RR:
2.08 CI 95%: 1.26–3.42) ( p = 0.012).
No association was found between the nursing diagnoses
and satisfaction among subjects in the sample.
4. Discussion
The study was intended to discover the frequency of
nursing diagnoses in the population cared for under the
portfolio of home care services in Andalusia, to determine
the link between nursing diagnoses and the use of home care
services, as well as any possible relationship linking nursing
diagnoses, mortality, institutionalisation and satisfaction.
With regards to frequency of diagnosis, currently there
are very few longitudinal studies on nursing phenomena in at
risk-populations. The resulting cases are a very valuable
source of data since, to date, all case studies on nursing
diagnoses during home care have been conducted with cross-
sectional designs, and consequently they have reported only
data relative to prevalence.
Our patients’ profile matches those which are usually
seen in our setting (Carpenter et al., 2004; Garcı́a-Calvente
et al., 2004; Moral et al., 2003), i.e. women of about 76 years
of age with a degree of functional dependency and severe
cognitive impairment and, therefore, extremely dependent in
basic activities; they live in the framework of normally
functioning families, are cared for by another woman—on
average of 56 years of age, usually the daughter or spouse,
who devotes a high number of hours daily to care and with
considerable overload.
‘‘Impairment of physical mobility’’ is the single compo-
nent that raises the highest incidence of nursing diagnoses.
This seems logical given that this is the central problem in
the population of this age and a great generator of depen-
dency and long-term care. Considering the results from
combining the compound variable of diagnoses that indicate
a high level of loss of independence and the use of health
care services, it seems that nurses have great expectation of
enhancing independence in those patients with a consider-
able loss of autonomy, to the point that they assign phy-
siotherapy resources to those who present with a lesser level
of functional deficit.
Nevertheless, it is possible that nurses may not have used
more specific labels for these patients such as ‘‘impaired
walking’’, ‘‘impaired movement in bed’’, ‘‘impaired move-
ment with the wheelchair’’, or ‘‘impaired ability to transfer’’,
that offer scope for intervention by increasing the know-how,
skills or will of the patient instead of solely applying care
replacement. The possibility of a lack of accuracy in the use
of differential diagnoses by nurses in the mobility domain
could be producing a bias in the selection of interventions.
Further research is needed in order to clarify whether this is a
training problem or a matter of ‘‘clinical inertia’’ (failure of
nurses to diversify or intensify interventions when needed).
The high incidence of ‘‘anxiety’’ that is equal to the
number of cases with ‘‘risk of caregiver strain’’ suggests to
us that ‘‘anxiety’’ probably precedes ‘‘strain in the role of
caregiver’’ in the natural history of nursing diagnoses where
the onset of ‘‘impaired sleep patterns’’ is one manifestation.
Patients with impaired mobility in the studies by Lee and
Mills (2000) and by Marek (1996) required fewer visits,
possibly as a result of differences in availability of service
provision, as this study was conducted within the framework
of the United States. Lee did not find that age or sex affected
the use of resources. Nevertheless, the population in Lee’s
study was different to ours (mean age 60.47 years and a
mean duration of home care of 34.34 days), despite similar
frequency of diagnoses per patient, these differed from
studies conducted in the Spanish context.
No association with major outcomes, such as institutio-
nalisation or patient or caregiver satisfaction, has been
observed although there is an issue that requires further
research, i.e. the relation between caregiver anxiety and
mortality rates among the elderly being cared for. In the
field of research on home care outcomes, there are still
certain outcomes that need to be fully accounted for since,
for instance, institutionalisation is not always due to a
decline in function, but rather deterioration in the family
support network (Godfrey et al., 2000). In this sense, the
family function for our sample was fairly good throughout
the entire study, which could account for the low rate of
institutionalisation. Nevertheless, placement is a major turn-
ing point in the lives of caregivers and there are many studies
that have demonstrated that stress and negative mental health
 J.M. Morales-Asencio et al. / International Journal of Nursing Studies 46 (2009) 189–196
cannot only remain, but increase with institutionalisation
(Gaugler et al., 1999). There is some social pressure in the
Spanish culture against institutionalisation of loved-ones,
above all in the more aged generations, that could be under-
lying in this low institutionalisation rates. Furthermore,
conceiving the caregiving experience as a career can account
for the dynamic stressors over time (Aneshensel et al.,
1995); it is plausible that our sample of caregivers would
not be in advanced phases of stress and this could contribute
to a low need of transition in the caregiving situation.
Nevertheless, it is very likely that the follow-up period in
our study has not been long enough to detect associations
in the long-term neither institutionalisation, nor mortality. In
the same way, satisfaction outcome was designed as a global
measure of the home care received, so it was rather unlikely
to detect any association with the presence or absence of
nursing diagnoses, but the research team did not want to
refuse the possibility of analyzing it. Further research with
specific satisfaction measures with nursing diagnoses utili-
sation is needed to elucidate this point.
Several studies identify nursing diagnoses as a comple-
ment to known case mixes (Welton and Halloran, 2005;
Ferrús et al., 2001) and others find a relation between nursing
diagnoses and outcomes (Rosenthal et al., 1992; Lavin et al.,
2004). Regarding this aspect, there is a certain variability
according to the units of measurement used to determine the
resources used and to forecast needs. In our study, the
number of visits was used, but there are other perspectives
based on the estimation of time devoted to care. For some
time, there has even been a greater dedication of nursing
time per visit when the home care recipient lives with his
wife (Trisolini et al., 1994). Another useful perspective
would be to measure the number of interventions performed
during the visit. Also pending is the challenge of verifying
the synergy of the Standardised Nursing Language Systems
with case-mix measures used in Primary Care, such as the
Ambulatory Care Groups (Weiner et al., 1991), but in view
of the highly explanatory capacity of some nursing diag-
noses in home care, i.e. the risk for caregiver strain, there is
no doubt that the combination with other systems would
notably improve the prediction of resource use and case-mix
in home care.
Role of funding sources
This study was granted by the Regional Ministry of
Health of Andalucia (project 134/02) and the National
Ministry of Health (Health Research Fund: PI031161).
Ethical approval
The study was approved by the Ethics Committee of the
Andalusian School of Public Health and by the respective
Healthcare Districts.
195
Conflict of interest
None declared.
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