Nursing Diagnosis of Grieving: Content Validityin Perinatal Loss SituationsOlga Paloma-Castro, MSc, RN, PhDc, José Manuel Romero-Sánchez, MScN, RN, PhDc,Juan Carlos Paramio-Cuevas, MSc, RN, PhDc, Sonia María Pastor-Montero, MScN, RN, PhDc,Cristina Castro-Yuste, MSc, RN, PhDc, Anna J Frandsen, MSc, RN, María Jesús Albar-Marín, PhD, RN, BPsych,Pilar Bas-Sarmiento, PhD, BPsych, and Luis Javier Moreno-Corral, PhD, MD, Ob/Gyn

Olga Paloma-Castro, MSc, RN, PhDc, is a Professor at the Nursing School of the University of Cádiz, Cádiz, Spain, JoséManuel Romero-Sánchez, MScN, RN, PhDc, is a Research Nurse of the Research Group under the Andalusian Research,Development, and Innovation Scheme CTS-391 of the University of Cádiz, Cádiz, Spain, Juan Carlos Paramio-Cuevas, MSc,RN, PhDc, is a Professor at the Nursing School “Salus Infirmorum” of the University of Cádiz, Cádiz, Spain, Sonia MaríaPastor-Montero, MScN, RN, PhDc, is a Hospital Nurse at Montilla Hospital, Córdoba, Spain, Cristina Castro-Yuste, MSc, RN,PhDc, is a Professor at the Nursing School of the University of Cádiz, Cádiz, Spain, Anna J Frandsen, MSc, RN, PhDc, is aResearch Nurse of the Research Group under the Andalusian Research, Development, and Innovation Scheme CTS-391 ofthe University of Cádiz, Cádiz, Spain, María Jesús Albar-Marín, PhD, RN, Bpsych, is a Professor at the Nursing School of theUniversity of Sevilla, Sevilla, Spain, Pilar Bas-Sarmiento, PhD, Bpsych, is a Professor at the Nursing School of the Universityof Cádiz, Cádiz, Spain, Luis Javier Moreno-Corral, PhD, MD, Ob/Gyn, is a Professor at the Nursing School of the Universityof Cádiz, Cádiz, Spain.

Search terms:Content validity, grief, nursingdiagnosis, perinatal loss, validationstudy

Palabras Clave:Diagnóstico enfermero, duelo,estudios de validación, perdidaperinatal, validez de contenido

Author contact:olga.paloma@uca.es, with a copyto the Editor: journal@nanda.org

PURPOSE: To validate the content of the NANDA-I nursing diagnosis of grievingin situations of perinatal loss.METHODS: Using the Fehring’s model, 208 Spanish experts were asked to assessthe adequacy of the defining characteristics and other manifestations identified inthe literature for cases of perinatal loss.FINDINGS: The content validity index was 0.867. Twelve of the 18 defining char-acteristics were validated, seven as major and five as minor. From the manifesta-tions proposed, “empty inside” was considered as major.CONCLUSION: The nursing diagnosis of grieving fits in content to the cases ofperinatal loss according to experts.IMPLICATIONS FOR NURSING PRACTICE: The results have provided evidenceto support the use of the diagnosis in care plans for said clinical situation.OBJETIVO: Validar el contenido del diagnóstico enfermero NANDA-I duelo encasos de pérdida perinatal.MÉTODO: Usando el modelo propuesto por Fehring, 208 expertos españolesevaluaron la adecuación a los casos de pérdida perinatal de las característicasdefinitorias y de otras manifestaciones identificadas en la literatura.RESULTADOS: El índice de validez de contenido fue de 0.867. Se validaron docede las dieciocho características definitorias, siete como mayores y cinco comomenores. De las manifestaciones propuestas, “vacío interior” fue consideradacomo mayor.CONCLUSIONES: El diagnóstico enfermero duelo se adecua en contenido a loscasos de pérdida perinatal según expertos.IMPLICACIONES PARA LA PRÁCTICA ENFERMERA: Los resultados apor-taron evidencia que apoya el uso del diagnóstico en planes de cuidados para esasituación clínica.

Currently, the NANDA-I classification contains over 200nursing diagnoses. However, it is in a continuous process ofreview and improvement to adapt to the daily practice ofnurses from all around the world and increase its levelsof scientific evidence. To make this one possible, diagnoses

must show to be suitable in practice, that is, to be validatedthrough research in different contexts and situations ortheoretical models. Despite the aforementioned and the callof multiple authors (Ackley & Ladwig, 2011) and the NANDA-Ito consider the validation of diagnoses as a priority to

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102 © 2013 NANDA International, Inc.International Journal of Nursing Knowledge Volume 25, No. 2, June 2014

improve care and increase the professional development,such studies are clearly insufficient on an international level(Lunney, 2009) and almost nonexistent at the Spanishsetting.

These validations will be of particular interest if they aremade based on life situations in which the intervention ofthe nurse is especially essential. The role of the nurse inclinical circumstances such as chronic diseases or depen-dence has been extensively studied (Bonill de las Nieves,2006). However, there are other circumstances in whichnursing care is equally indispensable, and which havereceived less attention. Perinatal loss is one of these cases,which includes losses occurring from the moment a womenknows that she is pregnant up to the neonatal period andgiving up a child for adoption, if applicable (Debackere, Hill,& Kavanaugh, 2008; Hutnik & Gregory, 2008; Hutti, 2005;Mathew, Cesario, & Symes, 2008).

Parents who suffer a perinatal loss experience the samereactions as those observed in other situations of grievingand may even become more intense due to the lack ofsocial visibility of perinatal bereavement (Gold, Dalton, &Schwenk, 2007). The emotional impact generated by thissituation is also experienced by involved healthcare profes-sionals (Gold, 2007; Pastor-Montero et al. 2011). This impactmakes tackling these situations difficult, where manycouples do not receive adequate care (Pastor-Montero,Vacas-Jaén, Rodríguez-Tirado, Marcías-Bezoya, & Pozo-Pérez, 2007). Sometimes, actions taken by health profes-sionals are guided by personal beliefs instead of evidence oreven the parents’ wishes (Claramunt, Alvarez, Jové, &Santos, 2009).

Nurses have a key role in addressing cases of perinatalloss by identifying the manifestations originated by the loss,planning, and implementing interventions and activitiesthat enable parents to accept this reality and develop ahealthy grieving process (Hutti, 2005; Pastor-Montero,2006). This approach requires a response based on evi-dence that enables the provision of quality, comprehensive,and systematic care (Pearson, Field, & Jordan, 2007; Wallin,2009), which involves the use of rigorous diagnostic termi-nology that catalogues human responses presented bypatients who suffer perinatal bereavement.

NANDA-I contains a nursing diagnosis (ND) “grieving(00136)” that, a priori, could be applied to these cases. Thisdiagnosis is defined as “a normal complex process thatincludes emotional, physical, spiritual, social, and intellec-tual responses and behaviors by which individuals, families,and communities incorporate an actual, anticipated, or per-ceived loss into their daily lives” (Herdman, 2012). This NDcontains 18 defining characteristics (DCs), observable cuesand inferences that can be clustered as manifestations ofthe diagnosis.

However, the lack of published research on the validityof this diagnosis and its DCs leads to the use of the diagno-sis with low levels of scientific support in relation to theclinical situation in which we find ourselves. Therefore,obtaining evidence that would allow for the verification that

the pre-identified DCs are grouped as manifestations in asufficient number of cases would indicate the existence of avalid diagnosis. This one would help nurses to know whatcharacteristics need to be identified to make the diagnosis,facilitating its recognition and giving them greater confi-dence in its use. Finally, it foments more appropriate careplanning for perinatal loss situations that would implybetter interventions with a direct benefit for patients.

In this sense, the overall objective of this study was tovalidate the content of the NANDA-I ND of grieving (00136)for its use in cases of perinatal loss. To this end, the follow-ing specific objectives were defined:

• Determine the Diagnostic Content Validity (DCV) index forthe nursing diagnosis of grieving and its DCs when appliedto cases of perinatal loss

• Explore the factor structure of the DCs• Determine the DCV index of specific manifestations of

perinatal loss identified in the literature

Methods

Study Design

An exploratory and descriptive study of DCV, followingthe model proposed by Fehring (1986, 1994), wasconducted.

Participants

Sampling and sample size. A convenience sample ofexpert nurses was selected through snowball sampling.While originally the number of experts needed to carry outa diagnostic content validation was set at 25–50 by theauthor of the method (Fehring, 1986), the participation of atleast 200 experts has been determined to conduct a factoranalysis (Nunnally & Bernstein, 1994). Whereas one of theobjectives of this study was to explore the factor structureof the DCs using this statistic, the minimum sample size wasestablished as 200 participants.

Inclusion, exclusion, and eligibility criteria. Criteria oftraining and experience in the areas where perinatal losssituations are most prevalent, in obstetric-gynecologicaland pediatric-neonatal nursing, were taken into account forthe consideration as being an expert in the said area (Lopes,Altino, & Silva, 2010; Wake, Fehring, & Fadden, 1991). Con-sequently, the following inclusion criteria were established:(a) possessing a degree of nurse practitioner in obstetricsand gynecology nursing (midwifery), (b) a minimum of 2years of professional experience in the area of obstetric-gynecological or pediatric-neonatal care, (c) a minimum of 2years of professional experience in university teaching inthe area of obstetric-gynecological or pediatric-neonatalcare. Refusal to participate in the study was considered asexclusion criterion. Eligibility criterion was to meet at leastone of the inclusion criteria and not the exclusion criteria.

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Recruitment of the sample. The cooperation of nursingdepartments in different hospitals, nursing scientific asso-ciations, and collaborators of the research team wasrequested to recruit the sample. The recruitment periodwas extended from August 2011 to January 2012.

Definition and Measurement of Variables

A questionnaire consisting of three sections, each onecorresponding to each set of the following variables:

• Socio-demographic variables: sex, age, direct care pro-vided to a case of perinatal loss at some time duringnursing career, position, experience as a nurse, andcurrent position and academic degree. The collection ofthese variables allowed for corroborating expert statusand performing a sample profile.

• DCs of NANDA-I ND of grieving (00136): The 18 DCs of theND of grieving were provided as presented in the Spanishversion of taxonomy (Herdman, 2009) (Table 2). Partici-pants were required to identify those, which according totheir experience and/or professional judgment, weremost representative in people who have suffered a peri-natal loss. Experts were asked to rate each DC on a scaleof 1 to 5 where: 1 = not at all characteristic or indicative ofthe diagnoses; 2 = very slightly characteristic of the diag-nosis; 3 = somewhat characteristic; 4 = considerably char-acteristic; and 5 = very characteristic (Fehring, 1986).

• Perinatal grief manifestations identified in existing litera-ture (Adolfsson, Larsson, Wijma, & Berterö, 2004;Badenhorst & Hughes, 2007; Swanson, Connor, Jolley,Pettinato, & Wang, 2007; Avelin, Rådestad, Säflund,Wredling, & Erlandsen, 2012): Self-criticism, ambivalentabout a new pregnancy, feelings of emptiness inside,social avoidance, sensation of slowing of time, feelings ofloneliness, longing, avoidance of pregnant women andbabies, feelings of socially unauthorized grief and audi-tory, visual and/or cenesthesic hallucinations (hearing thecry of the baby, ghost fetal movements, etc.). Expertswere requested to proceed in the same way as in theprevious DCs. The inclusion of this group of manifesta-tions was intended to determine whether they are repre-sentative of the diagnosis, and if appropriate, proposethem for inclusion as new DCs in upcoming revisions ofthe taxonomy.

Data Collection Procedure

To facilitate the dissemination and to obtain a samplewith representation across the country, the questionnairewas published in an online format, through a web-basedapplication. E-mails inviting to participate and directing toa link to the questionnaire were sent to the e-mailaddresses provided by the collaborators of the researchteam. An information letter was attached describing theobjective of the study and explaining the instructionsfor its completion and emphasizing how to rate the DCsproperly.

Data Analysis

Socio-demographic variables were summarized usingdescriptive statistics, expressing qualitative variables interms of frequency (n) and percentage (%) and quantitativevariables in terms of mean and standard deviation (SD).

To obtain the degree a DC was indicative of the diagnosisfor the clinical situation at hand, the score given by theexperts to each one was assigned a weight, so that 1 = 0,2 = 0.25, 3 = 0.50, 4 = 0.75, 5 = 1. The weighted average ofthe scores attributed to each of the DCs was calculated andrepresents the DCV index reaching values from 0 to 1. If thescore is greater than or equal to 0.8, the DC was consideredas highly representative of the diagnosis and catalogued as“major”. DCs with ratios less than 0.80 but greater than0.50 were considered as low representatives and labeled as“minor.” DCs obtaining values less than or equal to 0.5 wereconsidered not representative and therefore discarded.

Once the weights corresponding to each one of the DCswere assigned, the degree of representativeness of thefull diagnostic content for perinatal loss situations wasassessed calculating the overall DCV index. When an NDhas over seven DCs, it is recommended to follow theamendments proposed by Sparks and Lien-Gieschen(1994) to the original method by Fehring (1986, 1994).Since this is the case of the diagnosis of grieving, theseauthors’ premises were used for this study. They proposedto calculate the overall DCV index by counting the scoresof major DCs twice and the minor DCs once and thendetermining the arithmetic mean of all of them to avoidany artificial decreases. If the result was lower than 0.6,the diagnosis grieving should be considered as not repre-sentative in cases of perinatal loss, while if it were greaterthan 0.8 it would be considered representative. In thecase of obtaining a final value between 0.6 and 0.79, thedegree of representativeness of the diagnosis cannot bedetermined, requiring further studies to obtain decisiveresults.

To estimate how the DCs tend to cluster, an explora-tory factor analysis (EFA) was performed by meansof a principal component analysis (PCA) with Varimaxrotation. Previously it was determined if the initial corre-lation matrix allowed for the location of relevant group-ings between items through the Kaiser-Meyer-Olkin test(KMO) and Bartlett’s test of sphericity (Polit, 2010). Toset the appropriate number of factors, the followingcriteria were considered: (a) exploration of Cattell’s screeplot using the “elbow” criterion (Cattell, 1966), (b) theoverall variance accounted for by each factor, (c) the sim-plest possible structure (Child, 1990) where the loadings ofitems were as high as possible on their putative factorsand as low as possible on other factors (Kline, 1993). Therotated matrix was examined to identify the DCs thatsaturate each factor. Factor loads greater than 0.40 wereconsidered to define the factor well (Hair, Anderson,Tatham, William, & Black 1998) and consequently wereextracted.

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The manifestations proposed based on the literaturewere analyzed following an analogous procedure asdescribed above.

Results

Expert Profile

Two hundred and fifty questionnaires were sent, yieldinga response rate of 96.7%, representing a final sample of208 experts. Most of the participants were women (88%)with a mean age of 40.7 years (SD: 9.33). The averageexperience as a nurse was 17.50 years (SD: 9.43) and in thecurrent position for 9.98 years (SD: 8.52). Ninety-sixpercent of the sample had provided direct care to parentswho had suffered a perinatal loss sometime in their career.A sample of 86.4% had some kind of postgraduate training.The above results are presented in detail in Table 1.

Validation of the Defining Characteristics

Of the 18 DCs proposed for the diagnosis, 12 were vali-dated by experts. The DCV index for seven DCs reachedvalues to be considered as major and five as minor. The fiveother DCs were not considered indicative of the diagnosiswhen applied to perinatal grief. The DCV index achieved byeach DC is presented in Table 2. The DCV index was 0.867.

Factorial Structure

The KMO measure of sampling adequacy reached a valueof 0.797, indicating that the sample had a suitable level offactorability, and Bartlett’s test of sphericity was statisti-cally significant at the <0.000 level (X2 = 918.959; df = 136),implying that the correlation matrix was not identical to thefactor structure matrix. Both results support the pertinenceof the implementation of EFA. An initial examination ofCattell’s scree plot suggested the possibility of three- orfour-factor solutions, both with proper communality valuesand total variance explained. A four-factor solution wasinitially forced during the PCA extraction with varimax rota-tion, explaining 53.98% of the variance, and all DCs dem-onstrated factor loadings between 0.405–0.856 and twoDCs cross-loaded on two factors. Thus, the analysis wasrepeated, forcing a three-solution structure that explained46.43% of the variance with loadings between 0.418–0.785and three items cross-loaded on two factors. The rotatedmatrix for this structure is presented in Table 3. Consider-ing that the three-factor solution achieved the simpleststructure and that the variance explained is acceptable, itwas adopted as final. The labels given to each factor, theaccumulated variance, and DC included are presented inTable 4.

Validation of Manifestations Detected in ExistingLiterature

Of the 10 manifestations of perinatal grief proposalsidentified in existing literature, one was labeled by expertsas a major characteristic and eight as minor. One manifes-tation was not considered as representative. The DCV indexreached by each one is presented in Table 5.

Discussion

Eleven of the 18 DCs of the ND of grieving were identifiedby expert nurses as representative of those that occur inpeople who suffer a perinatal loss; seven of them wereconsidered as major. This, coupled with the high valuereached by the DCV index, supported its use in both indi-vidualized and standardized care plans for these cases.

The defining characteristics selected agglutinate a largenumber of manifestations that can be grouped in variousfields (Worden, 2008): emotional manifestations (major:blame, suffering, pain and despair; minor: anger, psycho-

Table 1. Socio-demographic Profile of Participants

Socio-demographic data n %

SexWoman 183 88Men 25 12Age<30 years 22 10.630–39 years 88 42.340–49 years 47 22.650–59 years 48 23.1≥60 years 3 1.4Work experience as nurse<5 years 11 5.35–9 years 36 17.310–19 years 79 38.020–29 years 49 23.6≥30 years 33 15.9Actual positionNurse practitioner in obstetrics and

gynecology nursing124 59.6

Nurse in obstetrics and gynecology ward 32 15.4Nurse in pediatrics and neonatology ward 20 9.6Nurse manager 23 11.1University professor 9 4.3Work experience in actual position<5 years 60 28.85–9 years 71 34.110–19 years 42 20.220–29 years 25 12.0≥30 years 10 4.8Direct care provided to a perinatal loss sometime in careerYes 201 96.6No 7 3.4Graduate courseNo 32 15.4Specialization 113 54.3Specialization + master’s program 22 10.6Master’s program 39 18.8Doctoral program 2 0.9

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logical distress), physiological manifestations (major:alteration in sleep patterns, alteration in dream pattern),cognitive manifestations (major: making meaning of theloss; minor: maintaining the connection to the deceased)and behavioral manifestations (minor: alteration in activitylevel, disorganization). Many of these manifestations are

supported by other studies that describe them as veryindicative in parents who lose a child (Avelin et al., 2012).

The selection by experts of a large number of DCs asrepresentative of perinatal loss shows the great impact of

Table 2. Diagnostic Content Validity (DCV) Index for Each One of the DCs

DC DCV Index SD

Major DCSuffering (Sufrimiento) 0.930 0.139Pain (Dolor) 0.901 0.182Making meaning of the loss (Búsqueda de significado de la pérdida) 0.852 0.206Blame (Culpa) 0.851 0.200Alteration in sleep patterns (Alteraciones en el patrón de los sueños) 0.845 0.171Alteration in dream patterns (Alteraciones en el patrón de los sueños) 0.841 0.170Despair (Desespero) 0.832 0.195Minor DCPsychological distress (Distrés psicológico) 0.762 0.214Anger (Cólera) 0.710 0.256Disorganization (Desorganzación) 0.691 0.242Alteration in activity level (Alteración del nivel de actividad) 0.688 0.218Maintaining the connection to the deceased (Mantenimiento de la conexión con la persona fallecida) 0.643 0.256Detachment (Desapego) 0.583 0.262Panic behavior (Conducta de pánico) 0.558 0.296Discard DCAlterations in neuroendocrine function (Alteraciones en la función neuroendocrina) 0.484 0.254Alterations in inmune function (Alteraciones de la función inmunitaria) 0.453 0.239Personal growth (Crecimiento personal) 0.405 0.299Experiencing relief (Experimentación de alivio) 0.257 0.259

Table 3. Factorial Matrix

DC

Factor loadings

1 2 3

Despair 0.785Blame 0.623Anger 0.610Disorganization 0.596Making meaning of the loss 0.522Suffering 0.513Detachment 0.487Pain 0.450Psychological distress 0.448Panic behavior 0.447 0.411Alterations in immune function 0.763Alteration in sleep patterns 0.448 0.709Alteration in dream patterns 0.439 0.709Alterations in neuroendocrine function 0.679Alteration in activity level 0.642Experiencing relief 0.691Personal growth 0.642Maintaining the connection to the

deceased0.418

Extraction method: Principal componentanalysis. Rotation method: Varimax withKaiser normalization

Table 4. Factorial Structure, Factor Labels, andVariance Explained by Each Factor

Factornumber Factor label DC

Variance%

1 Negativemanifestations

Despair 20.06BlameAngerDisorganizationMaking meaning of the

lossSufferingDetachmentPainPsychological distressPanic behavior

2 Physiologicalmanifestations

Alterations in immunefunction

15.93

Alteration in sleeppatterns

Alteration in dreampatterns

Alterations inneuroendocrinefunction

Alteration in activity level3 Positive

manifestationsExperiencing relief 10.44Personal growthMaintaining the

connection to thedeceased

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this on people who experience it, which is reflected in thepsycho-affective consequences and the individual actionsaimed at adapting and overcoming the loss.

Among the DCs considered as irrelevant, two were physi-ological manifestations, including alterations in the immuneand neuroendocrine functions, measurable only by labora-tory tests. The irrelevance assigned by the experts could bejustified based on the fact that nurses tend to make a moredirected assessment of emotional, cognitive, and behavioralmanifestations in such situations, evidenced through inter-views and observation. These manifestations are also moresusceptible to nursing interventions. Other DCs discardedwere those relating to the experimentation of relief or per-sonal growth that seem more characteristic of other situa-tions of grief, as is the case with caregivers who lose familymembers after suffering a particularly painful and lengthyillness (Schulz et al., 2003).

Factor analysis is a group of statistical techniques thathelp to identify unobservable factors underlying a set ofdata. They allow the analysis of the intercorrelations amongthem to establish certain groups of items correlated amongthemselves, which represent different dimensions of whatis being measured. The completion of the EFA on the scoresgiven by the experts yielded a grouping of the DCs intothree factors. The items composing factor 1, negative mani-festations, involved the affective, behavioral, and cognitivemanifestations produced by the experience of loss whenthe subject lives it as adverse, and factor 3, positive mani-festations, those produced if the loss is interpreted assomething comforting. Factor 2, physiological manifesta-tions, grouped the impact on systems and body processes.The choice of an exploratory approach in the factor analysisis justified in that, unlike others, the diagnosis grieving doesnot have its DCs grouped into categories (Herdman, 2012).Nurses, in the assessment phase of nursing process, orga-nized the data they collected both mentally and through

documentation, helping to begin to interpret the informa-tion to identify human responses and experiences, overlap-ping with the diagnostic phase (Alfaro-LeFevre, 1995). Theorganization of the DCs into predefined categories in thetaxonomy may help nurses to improve the processdescribed above. Factor analysis could be a technique toconsider establishing the underlying connections andgrouping of the DCs of approved and new diagnoses. Thegrouping into categories based on the evidence generatedby validation studies could make the organization of theDCs better suited to real contexts. In addition, if the facto-rial structure is consistent, it could be useful to endorse theconstruct validity of the diagnosis. However, it should benoted that, in this case, certain DCs considered as major bythe experts presented low factor loadings within theirfactors. This finding would indicate that not all DCs valuedas most representative of perinatal loss are associatedamong themselves based on what experts report. This maybe because grieving is a dynamic process; therefore, themanifestations of those who are grieving could be differentdepending both on the stage of grief or the context in whichthe death occurred (i.e., cultural setting, social supportnetwork, recurrent loss, early or late gestational loss,support received by health professionals, etc.). It wouldthus be appropriate to determine the influence on theresults of this study of these factors to improve the inter-pretation of the proposed factor structure in futureresearch.

With respect to the proposed manifestations of thosefound in the literature, only one was considered as major byexperts: feelings of emptiness inside. Based on this, itseems advisable to propose the inclusion of this manifesta-tion as a DC of the diagnosis grieving in future editions ofthe NANDA-I classification of nursing diagnoses, especiallyconsidering it is not a manifestation exclusive of the peri-natal losses but appears frequently in other grieving situa-tions, like the suicide of a loved one (Farberow, 1992) orwhen the child is the one who loses his or her parents(Auman, 2007).

All remaining manifestations that have been proposed,except one, were classified as minor. Of these manifesta-tions, “longing,” “avoidance of pregnant women andbabies,” “loneliness,” “social avoidance,” and “ambivalentabout a new pregnancy” scored very close to 0.80, thecutoff point between major and minor DC (Fehring, 1986).These manifestations should be considered in furtherstudies to determine whether they are indicative of thediagnosis. The only manifestation discarded was that whichreferred to the presence of hallucinations; although theymay occur in normal grieving, they are more characteristicof processes of complicated grieving (Simon et al., 2011),making it easier for the experts to identify it more with thelatter.

The results of this study were limited by deficienciesinherent to the validation model used: the consideration ofthe experts, their origin, the selection process, and variousnonconformities in the translation of the diagnosis. The

Table 5. Diagnostic Content Validity (DCV) Index forthe Manifestations Identified in the Literature

Manifestations found inliterature DCV Index SD

Major DCFeeling of emptiness inside 0.873 0.165Minor DCLonging 0.786 0.210Avoidance of pregnant women and babies 0.786 0.217Feelings of loneliness 0.775 0.215Social avoidance 0.748 0.223Ambivalent about a new pregnancy 0.734 0.240Self-criticism 0.679 0.220Feelings of socially unauthorized grief 0.661 0.263Sensation of slowing of time 0.630 0.234Discard DCAuditory, visual, and/or cenesthesic

hallucinations (hearing the cry of thebaby, ghost fetal movements, etc.)

0.483 0.257

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model DCV (Fehring, 1986) is based on retrospectiveimpressions of experts, and the information is not collectedin real time or directly from patients (Wake et al., 1991)favoring the appearance of biases like forgetfulness. Theconsideration of what makes a nurse an expert is anothersource of limitations related to the model. Fehring’s criteriato identify who may be considered an expert (Fehring, 1994)is difficult to apply in the Spanish context, where access tomaster’s and doctoral degrees was restricted to nursesuntil 5 years ago. This restriction is reflected in the studysample in which only 29.4% are master’s prepared, and0.9% are doctors. To overcome this difficulty, the recom-mendation of Levin (2001) of making flexible the consider-ation of experts was followed, and the criteria of trainingand experience was adopted as it is common in DCV studiesdeveloped in cultural contexts different from the one forwhich the model was developed (Lopes et al., 2010; Wakeet al., 1991). The selection of an unrepresentative samplemakes it impossible to generalize the results for all Spanishnurses. Similarly, the fact that it comes from a singlecountry limits the generalization at an international level,especially for the diagnosis here studied, as the response todeath or loss is culturally determined. Although grief isconsidered a universal stressor, its meaning and theresponses that it causes vary significantly from one cultureto another (Andrews & Hanson, 2003). It is thus assumedthat the validation in other cultural contexts would obtaindifferent results. Another factor to be considered was thepossible differences between the various translations of thetaxonomy (Table 2). It had been detected that in theSpanish version of the 2009–2011 edition of the taxonomy(Herdman, 2009), used in this study, the DCs “Alterationson dream pattern” and “Alteration on sleep pattern” aretranslated with the same expression as “Alteraciones en elpatrón de los sueños” (Alterations on the pattern ofdreams), equating the meaning of both DCs and losing thesubtle nuances of meaning of the original in English. Theword “sueño” in Spanish refers to both the act of sleep anddreaming. These non-conformities in the translation havealready been corrected in the Spanish version of the newedition (Herdman, 2012) by the introduction of a translationthat reflects the differential meaning of each DC properly.

Conclusions

The DCs of the ND of grieving fit in content to cases ofperinatal loss according to experts. The results increasedthe levels of evidence for its use in individualized and stan-dardized care plans for said clinical situation.

Of the new proposed manifestations based on the exist-ing literature, only “feelings of emptiness inside” was quali-fied as major; however, a large number of them qualified asminor. The proximity of the value achieved by these minormanifestations to the major cutoff point should be takeninto account. The research team intends to continue itsstudy, especially in clinical settings, since it could bethought that manifestations are not currently being evalu-

ated by professionals in the absence of specific assessmenttools for these situations validated in the Spanish setting.

At a methodological level, considering the use of factoranalysis as a technique when validating diagnosis would beideal. The classification into groups of DCs based onresearch can help nurses to systematize nursing assess-ment, facilitating mental order and documentary data col-lection. The dimensions resulting from factor analysis of theDCs can be considered to group them into new editions ofthe taxonomy, facilitating its usability.

The results of this research will be reported to theNANDA-I Diagnosis Development Committee to considerthe possibility of including these results in future editions ofthe classification and definition of ND.

Acknowledgments. The research team would like tothank all those who have believed in this project andgiven us their support, especially the Spanish Associationof Nomenclature, Taxonomy, and Nursing Diagnosis(AENTDE) and the associations of midwives: Matronas deÚbeda (http://matronasubeda.objectis.net/) andAsociación Profesional de Matronas del Principado deAsturias (http://www.matronasasturias.es/), as well aseveryone who participated by providing expertise; withoutthem this project would not have been possible.

Funding

This paper forms part of the fieldwork of the projectentitled “Validación del Diagnóstico Enfermero Duelo enCasos de Pérdida Perinatal” (Validation of the Nursing Diag-nosis Grieving in Perinatal Loss Situations), financed by theAndalusian Regional Ministry of Health (PI-0093-2012) inthe “2012 Call for Funding for Health Sciences & BiomedicalResearch Grants” after a rigorously peer-reviewed fundingprocess.

Author Contributions

All authors have agreed on the final version and meet atleast one of the following criteria:

• Substantial contributions to conception and design, acqui-sition of data, or analysis and interpretation of data;

• Drafting the article or revising it critically for importantintellectual content.

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