OF THE DEFINING CHARACTERISTICS IN THE NURSING DIAGNOSIS : WILLINGNESS TO IMPROVED RESILIENCE IN OSTOMIZED PATIENTS

Objective: to identify in the scientific literature, the defining characteristics of the nursing diagnosis “willingness to improved resilience” in studies conducted with ostomized people. Method: this was an integrative literature review conducted in the Latin American and Caribbean Health Sciences Literature, Medical Literature Analysis and Retrieval System Online, Bibliographic Spanish Index in Health Sciences, PubMed Central, Cumulative Index to Nursing and Allied Health Literature, Web of Science and SciVerse Scopus databases, using the non-controlled descriptors in the Medical Subject Headings vocabulary (MeSH): “Ostomy,” “Resilience”, “Psychological Adaptation” and “Quality of life”. The inclusion criteria were: scientific articles available in full; in Portuguese, English, and Spanish; with patients aged over 18 years, published between 2009 and 2014; and presenting at least one defining characteristic of the studied nursing diagnosis in their results. After the analysis, the final sample consisted of nine articles. Results: international studies predominated with the level of evidence VI. Among the defining characteristics, 10 out of 17, which are present in the NANDA International for nursing diagnosis “willingness to improved resilience,” were found in the literature. Conclusion: the defining characteristic presented in the taxonomy for the diagnosis “willingness to improved resilience” were found in studies with ostomized population.


INTRODUCTION
Ostomy is a surgical opening in the abdomen performed for therapeutic purposes to eliminate feces and/or urine.Digestive ostomies are subdivided into two types according to the segment to be externalized: ileostomy (opening in the ileum) and colostomy (opening in the colon), and can be classified as temporary or permanent. 1ccording to the United Ostomy Associations of America (UOAA), it is estimated that in 2013 there were more than 750 thousand ostomized people and 120 thousand new ostomy surgeries were performed annually in the United States of America (USA).] Patients undergoing ostomy often present altered social and psychological patterns as the result of a change in life expectancy due to the change in their body image, elimination, nutrition, and hygiene habits among others. 4he adaptation after an ostomy surgery varies from one individual to another.For some, it will be a problem, for others, a challenge.Each patient will physically and psychologically adapt in their own way and in their own time.To help them in the process of adaptation, the multidisciplinary team involvement in the care process is of fundamental importance; the team can provide the necessary support to the patient's demands: selfcare, self-esteem, body image, sexuality, and resilience. 2 The term "resilience" means the ability that an individual has to adapt and respond positively to experiences that have potential risk to his health and development. 5In line with this, the NANDA International (NANDA-I) conceptualizes the nursing diagnosis (DE) "willingness to improved resilience" as a pattern of positive responses to a situation or adverse crisis that is sufficient to optimize the human potential and can be reinforced. 6hat sustains the identification of a DE for health promotion are the defining characteristics identified from the analysis of subjective and objective data gathered during the first stage of the nursing process. 6he use of DEs highlights the clinical reasoning of nurses on the need expressed by patients.In the context of ostomized people, the resilience must be the nurses' focus of attention; the correct use of diagnostic language is necessary to identify whether the defining characteristics present in the taxonomy are related to this population.
The nursing team, through the technical and scientific knowledge, is able to assist in the rehabilitation of ostomized people, their new condition of life, and develop the teachinglearning for self-care aiming at improving the quality of life of this population. 7herefore, the development of coping strategies that enable these individuals to become resilient and psychologically adapted to their new life situation is necessary.
Hence, this study aimed to identify in literature the defining characteristics of the nursing diagnosis "willingness to improved resilience" in studies conducted with ostomized people.

METHODOLOGY
This was an integrative literature review, carried out based on the preparation of a research protocol, with a view to planning and systematization containing the following information: subject of review, objective, guiding question, search strategies, databases, descriptors adopted in the search, crossing descriptors, inclusion and exclusion criteria, strategies for data collection in the studies, strategy for critical evaluation, and strategy for data synthesis.
The following steps were used in the construction of this study: theme identification and selection of the research question, establishing criteria for the inclusion and exclusion of studies, identification of pre-screened and selected studies, categorization of studies, analysis and interpretation of results, and presentation of the review/synthesis of knowledge. 8he following guiding question was formulated to conduct this review: what are the defining characteristics found in the literature and related to the nursing diagnosis "willingness to improved resilience" in people with ostomies?The search strategy step occurred from July to August of 2014 in the Latin American and Caribbean Health Sciences Literature (LILACS), Medical Literature Analysis and Retrieval System Online (MEDLINE), Bibliographic Spanish Index in Health Sciences (IBECS), PubMed Central, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Scopus Sci-Verse (SCOPUS) databases.
proposed and validated by Ursi 9 , which brings together the following components in the analysis of titles and abstracts of publications: title, author, database, journal, year of publication, country, method of approach, study nature, objective, indicator, level of evidence, and study population.Subsequently, the selection of papers that would be read in full was performed based on the consensus among these researchers.A total of 702 articles were found in the seven surveyed databases through the application of the study descriptors.Sixty articles were excluded because they were duplicates after cross-checking all databases.After the reading of titles and abstracts, 41 studies were selected and considered potentially relevant.After a critical analysis, 33 studies were selected for reading in full.After exhaustive reading, nine articles were selected based on their fit in responding the objective of this study; these articles composed the final sample for this review, five from SCOPUS, two from MEDLINE, one from LILACS, and one from CINAHL (Table 1).
descriptor "Resilience", few relevant studies were found.As a result, the descriptor "Psychological Adaptation" was also adopted because it is synonymous to the descriptors in Health Sciences (DeCS) -Terminology in Health.
The choice of non-controlled descriptors was based on the limited amount of publications concerning the objective of this study.The intersection of these descriptors resulted from the use of the Boolean operator AND in combination.
Studies that met the following criteria were included in the research: scientific articles available in full; in Portuguese, English, and Spanish; with patients aged over 18 years, published between 2009 and 2014; and with results of at least one defining characteristic of the studied nursing diagnosis.Studies in an editorial format, letters to the editor, and literature reviews were excluded.
The study selection procedure was performed independently by two researchers using the data collection instrument Selected articles were classified according to levels of evidence using a classification system comprised of seven levels: level I -evidence from systematic reviews or meta-analysis of relevant clinical trials; level II -evidence derived from at least one randomized controlled clinical trial clearly delineated; level III -well-designed clinical trials without randomization; level IV -cohort studies and well-designed case-control; level V -systematic reviews of descriptive and qualitative studies; level VI -evidences derived from one single descriptive or qualitative study; and level VII -authorities' opinion or reports from specialized committees. 10egarding the ethical aspects of studies, the authorship of all studied articles was respected.

RESULTS
Out of the seven surveyed databases, the Web of Science and PubMed did not add studies to the sample.Descriptive studies were predominant, with a total of seven (88.9%), three (33.3%)published in 2014, and five (55.5%) performed in the United States of America -USA; all nine selected studies (100.00%)showed level of evidence VI. (Table 2).
Among the defining characteristics, 10 out of the 17 characteristics present in the nursing diagnosis "willingness to improved resilience" were found in the literature.Some identified available resources -nine (100.0%);some identified support systems -five (55.5%); some demonstrated positive outlook -five (55.5%); and some provided access to resources -four (44.4%); these characteristics were the most prevalent in the evaluated studies.Table 3 describes the distribution of studies according to the defining characteristics found.
In the target population addressed in the studies, there was a predominance of ostomized patients for at least five years after diagnosis -three (33.3%); ostomized patients for two months or more -three (33.3%); followed by an indeter-minate time since ostomy -two (22.2%); and ostomized patients for less than one year -one (11.1%) (Table 4).
... continuation  by the group, which becomes very beneficial on their journey to physical recovery and psychological adjustment. 24,25he nursing consultation is essential for the rehabilitation of patients because it offers the necessary support for treatment and a direction, guiding the patient to acceptance by understanding the changes in their bodies.Ostomized patients who often attend the nursing consultations are the very ones who had the best adaptation to ostomization.][27] The identification of available resources and access to them, such as special equipment, provides security for ostomized patients by knowing that there are bags and quality materials available to perform their care, which positively influences their personal autonomy. 27nother important resource is the search for strength in religious faith, which provides resilience and improved quality of life.Spiritual well-being is a key player in the process of resilience in ostomized patients. 28,29he defining characteristic "demonstrates positive outlook" is paramount in assessing resilience in ostomized people because they are faced with a new situation in life where their body images that were built over a lifetime are destroyed due to the presence of a device in the abdominal wall where feces are continuously collected without control, leading to a profound alteration in self-steem. 16hus, the demonstration of a positive outlook is critical for ostomized people because accepting their own bodies in a gradual and positive manner help them facing limitations, accepting the situation considering their impotence in reversing it, and thus, adapting to live with the ostomy. 30he defining characteristic "improves in personal coping skills" is of paramount importance in the adaptation process because living with ostomy not only affects the intestines but also influences the diet and feeding habit. 31hanges in eating habits are mentioned as strategies for improved personal coping because the intake of certain foods causes excessive gas production, resulting in social discomfort.Therefore, ostomized people choose to seek guidance about foods; based on a new nutrition they can minimize the emission of gasses and control bowel movements. 32,33nother form of coping is the use of large shirts and pants to accommodate better the ostomy.Many shared having renewed their wardrobes with clothes that meet their needs and hence improve their adaptation to an altered body image. 32,34n the process of resilience, reports on the individual psychological development of a healthy body image and self-esteem are fundamental for the ostomized person facing a new situation.However, the literature shows that ostomized individuals have declined self-esteem and self-image, demonstrat-

DISCUSSION
In this study, a predominance of surveyed studies classified with a level of evidence was observed.These studies are characterized by descriptive studies (non-experimental) and/ or with a qualitative approach, which aims to analyze and interpret texts based on subjectivity, providing rich narratives and broad description of results.These findings highlight the need for studies with high levels of relevance that may support the clinical practice of nursing professionals, especially in relation to ostomized patients because the number of procedures associated with the estimated incidence rate of colorectal cancer grows every year, with 30,660 new cases in 2014. 9,20he US' dominance as the location of studies reveals the frequency of international research on the subject in question.This fact is explained by the majority of surveyed databases being international and the use of descriptors in English in this study.
The defining characteristics "identifies available resources", "identifies support systems" and "engages in activities" present in the 'willingness to improved resilience" DE were the most present in the literature, highlighting the importance of these evidence in the process of resilience of ostomized patients.
Living with an ostomy requires the adoption of numerous measures of adaptation and adjustment by the patient, such as learning about self-care and handling of devices.The search for support systems is essential to the restoration of independence and self-confidence in ostomized patients. 18,21orroborating the previous statement, one of the strategies used by ostomized people in their adaptation process is the search for information about their disease, either with the guidance of health professionals or the participation in support groups that enable the exchange of experiences among ostomized patients. 22,23he system of support groups for ostomized people allows individuals to talk openly about their fears and sorrows and ask questions to stomach therapy nurses and other ostomized patients about issues related to their treatment, building trust between the health team and the group, making them realize that they are not alone, and thus, restoring social relations from simple conversations and engaging in activities proposed ing negative feelings about their own bodies, reinforcing the findings of this study because the defining characteristic "reports self-esteem" was found in only one of the studies. 35,36he adaptation to living with ostomy requires a long and continuous process in which various aspects directly and indirectly influence the final result.A study demonstrates that patients ostomized for more than two years have a better quality of life as the result of the various skills developed and psychological and social aspects involved in the adaptation process. 37

CONCLUSION
After the analysis of studies, it was verified that the nursing diagnosis "willingness for improved resilience" can be identified in ostomized people because out of the 17 defining characteristics of this diagnosis, 10 were found in the literature for this population.
The results showed that the most frequent defining characteristics were: identifies available resources, identifies support systems, provides access to resources, and demonstrates a positive outlook.The studied populations were mostly composed of patients ostomized in at least two months or more.
One of the limitations of this study is the shortage of scientific publications on the resilience of ostomized people; the use of synonyms was necessary for the execution of the study.
This study shows that by implementing the steps of the nursing process, it is possible to extend the care targeted for the ostomized population, identifying the relevant nursing diagnoses for these individuals and developing, from their formulation, a plan and the implementation of care that will enable these patients to develop the resilience to face positively the new life context in which they live.
In the nursing context, the formulation of a diagnosis for health promotion is crucial to highlight the willingness of patients to achieve a higher a superior wellness level and thereby, help them realize the potential for human health.

Table 1 -
Quantitatives for the: identified studies (L), potentially relevant studies (R), duplicated and excluded studies (D), studies selected for reading in full (S), and final sample (A).Brazil, 2014

Table 1 -
Quantitatives for the: identified studies (L), potentially relevant studies (R), duplicated and excluded studies (D), studies selected for reading in full (S), and final sample (A).Brazil, 2014

Table 2 -
Studies distribution according to databases, study type, publication year, country, and level of relevance.Brazil, 2014 Source: prepared by the author.

Table 3 -
Identification of the defining characteristics of the nursing diagnosis "willingness to improved resilience".Brazil, 2014 Source: prepared by the author.

Table 4 -
Distribution of studies according to time since ostomy in the studied target population.Brazil, 2014