Evidence-based Practice Questionnaire

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Evidence-based Practice Questionnaire
Official Organization for Scientific Dissemination of the Escola
Paulista de Enfermagem, Universidade Federal de São Paulo
Acta Paulista de Enfermagem/ Escola Paulista de Enfermagem/ Universidade Federal de São Paulo
Address: Napoleão de Barros street, 754, Vila Clementino, São Paulo, SP, Brazil. Zip Code: 04024-002
Acta Paul Enferm. volume 27, issue(5), September/October 2014
ISSN: 1982-0194 (electronic version)
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Sonia Maria Oliveira de Barros
Acta Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
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Edna Terezinha Rother
Acta Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Associate Editors
Ana Lucia de Moraes Horta, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Bartira de Aguiar Roza, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Elena Bohomol, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Elisabeth Niglio de Figueiredo, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Erika de Sá Vieira Abuchaim, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Manuela Frederico-Ferreira, Escola Superior de Enfermagem de Coimbra, Coimbra, Portugal
Rosely Erlach Goldman, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Sonía Ramalho, Instituto Politécnico de Leiria, Escola Superior de Saúde de Leiria, Leiria, Portugal
Tracy Heather Herdman, University of Wisconsin, CEO & Executive Director NANDA International, Green Bay-Wisconsin, USA
Editorial Board
National
Alacoque Lorenzini Erdmann, Universidade Federal de Santa Catarina-UFSC, Florianópolis-SC, Brazil
Ana Cristina Freitas de Vilhena Abrão, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Cibele Andrucioli de Matos Pimenta, Escola de Enfermagem da Universidade de São Paulo-EE/USP, São Paulo-SP, Brazil
Circéa Amália Ribeiro, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Conceição Vieira da Silva-Ohara, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Elucir Gir, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Emília Campos de Carvalho, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Isabel Amélia Costa Mendes, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Isabel Cristina Kowal Olm Cunha, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Ivone Evangelista Cabral, Escola de Enfermagem Anna Nery- EEAN/UFRJ, Rio de Janeiro-RJ, Brazil
Janine Schirmer, Universidade Federal de São Paulo-USP, São Paulo-SP, Brazil
Josete Luzia Leite, Escola de Enfermagem Anna Nery - EEAN/UFRJ, Rio de Janeiro-RJ, Brazil
Lorita Marlena Freitag Pagliuca, Universidade Federal do Ceará-UFC, Fortaleza-CE, Brazil
Lúcia Hisako Takase Gonçalves, Universidade Federal de Santa Catarina-UFSC, Florianópolis-SC, Brazil
Margareth Ângelo, Universidade de São Paulo-USP, São Paulo-SP, Brazil
Margarita Antônia Villar Luís, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Maria Antonieta Rubio Tyrrel, Escola de Enfermagem Anna Nery- EEAN/UFRJ, Rio de Janeiro-RJ, Brazil
Maria Gaby Rivero Gutiérrez, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Maria Helena Costa Amorim, Universidade Federal do Espírito Santo-UFES, Vitória-ES, Brazil
Maria Helena Lenardt, Universidade Federal do Paraná-UFP, Curitiba-PR, Brazil
Maria Helena Palucci Marziale, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Maria Júlia Paes da Silva, Universidade de São Paulo-USP, São Paulo-SP, Brazil
Maria Márcia Bachion, Universidade Federal de Goiás-UFG, Goiânia-GO, Brazil
Maria Miriam Lima da Nóbrega, Universidade Federal da Paraíba-UFPB, João Pessoa-PB, Brazil
Mariana Fernandes de Souza, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
I
Mavilde da Luz Gonçalves Pedreira, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Paulina Kurcgant, Universidade de São Paulo-USP, São Paulo-SP, Brazil
Raquel Rapone Gaidzinski, Universidade de São Paulo-USP, São Paulo-SP, Brazil
Rosalina Aparecida Partezani Rodrigues, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Silvia Helena De Bortoli Cassiani, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Telma Ribeiro Garcia, Universidade Federal da Paraíba-UFPB, João Pessoa-PB, Brazil
Valéria Lerch Garcia, Universidade Federal do Rio Grande-UFRGS, Rio Grande-RS, Brazil
International
Barbara Bates, University of Pennsylvania School of Nursing - Philadelphia, Pennsylvania, USA
Donna K. Hathaway, The University of Tennessee Health Science Center College of Nursing; Memphis, Tennessee, USA
Dorothy A. Jones, Boston College, Chestnut Hill, MA, USA
Ester Christine Gallegos-Cabriales, Universidad Autónomo de Nuevo León, Monterrey, Mexico
Geraldyne Lyte, University of Manchester, Manchester, United Kingdom, USA
Helen M. Castillo, College of Health and Human Development, California State University, Northbridge, California, USA
Jane Brokel, The University of Iowa, Iowa, USA
Joanne McCloskey Dotcherman, The University of Iowa, Iowa, USA
Kay Avant, University of Texas, Austin, Texas, USA
Luz Angelica Muñoz Gonzales, Universidad Nacional Andrés Bello, Santiago, Chile
Margaret Lunney, Staten Island University, Staten Island, New York, USA
María Consuelo Castrillón Agudelo, Universidad de Antioquia, Medellín, Colombia
Maria Müller Staub, Institute of Nursing, ZHAW University, Winterthur, Switzerland
Martha Curley, Children Hospital Boston, Boston, New York, USA
Patricia Marck, University of Alberta Faculty of Nursing, Edmonton Alberta, Canada
Shigemi Kamitsuru, Shigemi Kamitsuru, Kangolabo, Tokyo, Japan
Sue Ann P. Moorhead, The University of Iowa, Iowa, USA
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II
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III
Editorial
C
linical reasoning is an analytical approach, based on disciplinary
knowledge, which clusters and integrates data to arrive at the most
accurate diagnosis and best therapeutic plan for patients/families/
communities. Thus, nursing diagnosis is the outcome of a nurse’s clinical
reasoning – just as medical diagnosis is the outcome of a physician’s clinical
reasoning. We cannot accurately diagnose without applying clinical reasoning and domain-specific knowledge.
When we focus primarily on medical diagnosis and intervention in lectures and course work, what are we teaching students? If we expect nurses
to primarily manage medication administration and perform medical interventions, what are we emphasizing as important for nursing practice? If we
focus research solely on intervention or symptom management, what are
we saying about nurses’ ability to diagnose and claim responsibility for their
practice? And if we have no time to assess or diagnose patients because we
have too few nurses, too many patients, too many medical orders – who is
truly caring for the whole patient and his/her family?
This is nursing’s role – a holistic view of patient/family/community – assessment and diagnosis (clinical judgments) concerning human responses
to health conditions/life processes, or a vulnerability for that response, by
individuals/families/groups/communities. Our diagnoses should provide
the basis for evidence-based nursing interventions to achieve outcomes for
which we have accountability. Are we teaching and valuing nursing concepts/phenomena of concern to our discipline? Are we standing strong in
our role of advocacy for the whole person – which goes beyond tasks related
to medical diagnoses? Does our research reflect our knowledge base?
Will we meet the challenge of clinical reasoning from a nursing perspective, or will we maintain the status quo - teaching medical concepts
and diagnoses, which we are not licensed to diagnose, relegating our role to
the fulfillment of physician-ordered interventions? We must work with our
physician colleagues to provide care that integrates the best of both disciplines, rather than emphasizing one discipline over the other.
T. Heather Herdman
RN, PhD, FNI
University of Wisconsin (Green Bay) and CEO/Executive Director, NANDA International, Inc
DOI: http://dx.doi.org/10.1590/1982-0194201400065
IV
Contents
Original Articles
Functional capability and violence situations against the elderly
Capacidade funcional e situações de violência em idosos
Andréa Mathes Faustino, Lenora Gandolfi, Leides Barroso de Azevedo Moura������������������������������������������������������������������������ 392
Quality of life of frail elderly users of the primary care
Qualidade de vida de idoso fragilizado da atenção primária
Maria Helena Lenardt, Nathalia Hammerschmidt Kolb Carneiro, Jéssica Albino, Mariluci Hautsch Willig���������������������������� 399
Cultural adaptation to Brazil and psychometric performance
of the “Evidence-Based Practice Questionnaire”
Adaptação cultural para o Brasil e desempenho psicométrico do “Evidence-based Practice
Questionnaire”
Karina Rospendowiski, Neusa Maria Costa Alexandre, Marilia Estevam Cornélio������������������������������������������������������������������� 405
Effectiveness of antiemetics in control of antineoplastic
chemotherapy-induced emesis at home
Efetividade de antieméticos no controle da emese induzida pela quimioterapia antineoplásica, em
domicílio
Marielly Cunha Castro, Suely Amorim de Araújo, Thaís Rezende Mendes, Glauciane Silva Vilarinho,
Maria Angélica Oliveira Mendonça����������������������������������������������������������������������������������������������������������������������������������������� 412
Cross-cultural adaptation of the primary health care satisfaction questionnaire
Adaptação transcultural do questionário de satisfação com os cuidados primários de saúde
Elisabete Pimenta Araujo Paz, Pedro Miguel Santos Dinis Parreira, Alexandrina de Jesus Serra,
LoboRosilene Rocha Palasson, Sheila Nascimento Pereira de Farias����������������������������������������������������������������������������������������� 419
Biopsychosocial aspects and the complexity of care of hospitalized elderly
Aspectos biopsicossociais e a complexidade assistencial de idosos hospitalizados
Beatriz Aparecida Ozello Gutierrez, Henrique Salmazo da Silva, Helena Eri Shimizu�������������������������������������������������������������� 427
Expression of domestic violence against older people
Expressão da violência intrafamiliar contra idosos
Luana Araújo dos Reis, Nadirlene Pereira Gomes, Luciana Araújo dos Reis, Tânia Maria de Oliva Menezes,
Jordana Brock Carneiro����������������������������������������������������������������������������������������������������������������������������������������������������������� 434
Assessment of attributes for family and community
guidance in the child health
Avaliação dos atributos de orientação familiar e comunitária na saúde da criança
Juliane Pagliari Araujo, Cláudia Silveira Viera, Beatriz Rosana Gonçalves de Oliveira Toso, Neusa Collet,
Patrícia Oehlmeyer Nassar������������������������������������������������������������������������������������������������������������������������������������������������������� 440
Validity of instruments used in nursing care for people with skin lesions
Validade de instrumentos sobre o cuidado de enfermagem à pessoa com lesão cutânea
Roberta Kaliny de Souza Costa, Gilson de Vasconcelos Torres, Marina de Góes Salvetti, Isabelle Campos de Azevedo,
Maria Antônia Teixeira da Costa��������������������������������������������������������������������������������������������������������������������������������������������� 447
V
Violence against women and its consequences
Violência contra a mulher e suas consequências
Leônidas de Albuquerque Netto, Maria Aparecida Vasconcelos Moura, Ana Beatriz Azevedo Queiroz,
Maria Antonieta Rubio Tyrrell, María del Mar Pastor Bravo��������������������������������������������������������������������������������������������������� 458
Breastfeeding self-efficacy: a cohort study
Autoeficácia na amamentação: um estudo de coorte
Erdnaxela Fernandes do Carmo Souza, Rosa Áurea Quintella Fernandes�������������������������������������������������������������������������������� 465
Risks related to drug use among male construction workers
Risco relacionado ao consumo de drogas em homens trabalhadores da construção civil
Aroldo Gavioli, Thais Aidar de Freitas Mathias, Robson Marcelo Rossi, Magda Lúcia Félix de Oliveira���������������������������������� 471
The effect of Reiki on blood hypertension
Efeito do Reiki na hipertensão arterial
Léia Fortes Salles, Luciana Vannucci, Amanda Salles, Maria Júlia Paes da Silva����������������������������������������������������������������������� 479
Craniocerebral trauma in motorcyclists: relation
of helmet use and trauma severity
Traumatismos craniocerebrais em motociclistas: relação do uso do capacete e gravidade
Viviane da Cunha Dutra, Rita Catalina Aquino Caregnato, Maria Renita Burg Figueiredo, Daniela da Silva Schneider �������� 485
Nursing actions in homecare to extremely low birth weight infant
Ações de enfermagem na assistência domiciliar ao recém-nascido de muito baixo peso
Anelize Helena Sassá, Maria Aparecida Munhoz Gaíva, Ieda Harumi Higarashi, Sonia Silva Marcon������������������������������������� 492
VI
Original Article
Functional capability and violence
situations against the elderly
Capacidade funcional e situações de violência em idosos
Andréa Mathes Faustino1
Lenora Gandolfi1
Leides Barroso de Azevedo Moura1
Keywords
Geriatrics nursing; Nursing care;
Activities of daily living; Elder abuse;
Violence
Descritores
Enfermagem geriátrica; Cuidados de
enfermagem; Atividades cotidianas;
Maus-tratos ao idoso; Violência
Submitted
February 8, 2014
Accepted
June 26, 2014
Abstract
Objective: To verify whether there is a connection between the functional capacity of the elderly and the
presence of violent situations in their daily lives.
Methods: A population-based cross-sectional study developed with 237 elderly individuals. Standard and
validated research instruments were used.
Results: Mean age of 70.25 years (standard deviation of 6.94), 69% were female, 76% were independent in
basic activities of daily living and 54% had a partial dependence on at least one instrumental activity. The most
prevalent violence was psychological and the relation between being dependent on basic activities of daily
living and suffering physical violence was statistically significant.
Conclusion: When the elderly needs assistance to perform self-care activities, there is a greater chance of
exposure to a situation of abuse, such as physical violence.
Resumo
Objetivo: Verificar se há relação entre a capacidade funcional do idoso e a presença de situações de violência
em seu cotidiano.
Métodos: Trata-se de estudo transversal de base populacional com 237 idosos. Foram utilizados instrumentos
de pesquisa validados e padronizados.
Resultados: A média de idade de 70,25 anos (desvio padrão de 6,94), 69% eram do gênero feminino,
76% eram independentes nas Atividades Básicas de Vida Diária e 54% possuíam dependência parcial em
pelo menos uma atividade instrumental. A violência mais prevalente foi a psicológica e foi estatisticamente
significativa a relação entre ser dependente em Atividades Básicas de Vida Diária e sofrer violência física.
Conclusão: Quando o idoso necessita de ajuda para realizar atividades de autocuidado, maior é a chance de
exposição à situação de maus-tratos do tipo violência física.
Corresponding author
Andréa Mathes Faustino
Campus Darcy Ribeiro, Asa Norte,
Brasília, DF, Brazil.
Zip Code: 70910-900
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400066
392
Acta Paul Enferm. 2014; 27(5):392-8
Universidade de Brasília, Brasília, DF, Brazil.
Conflicts of interest: there are no conflicts of interest to declare
1
Faustino AM, Gandolfi L, Moura LB
Introduction
The natural process of aging, associated to chronic diseases, can favor functional disability. This will
lead to an increased vulnerability of the elderly,
which makes them more susceptible to suffering
abuse.(1)
The definition for functional disability is the
inability or difficulty in performing everyday tasks
of human beings, which are usually necessary for
an independent life in the social environment.
The functional capability would be the potential
to perform the activities of daily living or a certain
action without needing the help of others, which
is determinant to maintain quality of life and independence.(2)
The results obtained in evaluating functional
capability allow to learn the profile of the elderly,
regarding their functionality in everyday activities,
which allows to identify situations that need an intervention for health promotion, in order to postpone the disabilities inherent to aging.(3)
Violence and abuse against the elderly can be
defined as a single and repeated act, or the lack
of appropriate measures in abuse situations, which
occur in any relationship where there is an expectation of trust and causes harm or distress to an
elder person.(4)
Regarding the nature of violence, there is a
basic typology of violence committed against an
elderly individual, consisting of psychological
violence (verbal or gestural aggression), physical
violence (use of physical force with the intention
of harm and the inappropriate use of chemical
and physical restrictions), sexual violence (sexual
game or act against the will or without consent),
abandonment (lack of care by the legal responsible individual), neglect (refusal of care by the
responsible individual), material and/or financial exploitation (non-consensual use of material
and/or financial assets) and self-neglect (any kind
of behavior from the elderly that endangers their
health and safety).(5)
Some risk factors in the elderly involved in
violence situations have already been described
by several authors; among which: having some
type of dementia, physical disability, depression,
loneliness or lack of social support; using alcohol
or illicit drugs; living in conflict situations with
the caregiver; and presenting signs of reduced
cognitive and functional capacity. The presence
of these factors may favor the increase of dependency for self-care in instrumental and basic activities of daily living and, therefore, increase the
possibility of suffering abuse in their community
environment.(6-8)
The objective of this study is to verify the relation between the functional capacity of the elderly and the presence of violence situations in their
daily lives.
Methods
A population-based cross-sectional study, with a descriptive observational design, was developed with
the elderly population assisted at a primary health
care service, in Brasília, Distrito Federal, midwest
region of Brazil.
The criteria for inclusion in the sample were: being 60 years old or over, of both genders, attending
a health care service during the data collection period, not having a diagnosis of dementia and agreeing
to participate in the study.
The elderly were individually approached after a
medical consultation and in a private room, where
face-to-face interviews were conducted, with an average duration of 50 minutes. Data were collected
between July 2012 and November 2013.
The instrument used to assess the performance
in basic activities of daily living was the scale proposed by Katz, which assesses the level of dependency of the individual to perform a set of six self-care
daily activities: bathing, dressing, personal hygiene,
transferring, continence and feeding.(9)
The result of the Katz score may vary from 6
to 18 points and, for analysis purposes, the following classification for the interpretation of the
scores was used, with the following response options: does not receive any assistance, 3 points;
receives partial assistance, 2 points; and does not
perform the activity, 1 point.(10)
Acta Paul Enferm. 2014; 27(5):392-8
393
Functional capability and violence situations against the elderly
The Lawton scale was chosen to assess the instrumental activities of daily living. This instrument assesses functional performance in more
complex activities, such as using the telephone,
going to distant locations using a means of transportation, shopping, preparing meals, cleaning
the house, doing domestic manual work, washing and ironing clothes, taking medications correctly and taking care of finances. The scores may
vary between 9 and 27 points and, in terms of the
classification on the level of dependence, there
are 27 points for independence, from 26 to 18
points to partial dependence and ≤18 points for
total dependence.(11)
A data collection instrument was created to
approach the violence situations, consisting of
semi-structured questions validated by a group
of experts in the gerontology field, comprising
personal and socio-demographic information, as
well as information in terms of the nature of the
violence (psychological, physical, sexual, abandonment, neglect, financial abuse and self-neglect).
The results were processed and tabulated on
the Bioestat program, version 5.3. Descriptive statistics and percentage and absolute frequency tables were used for treatment data. The associations
between the categorical variables were studied by
means of the Chi-square test and significance was
set at 0.05.
The development of this study complied with
national and international ethical guidelines for research involving human beings.
Results
The sample consisted of 237 elderly individuals,
of which 69.9% were female. The mean age was of
70.25 years (standard deviation of 6.94), ranging
between 60 and 93 years. The most predominant
age group was between 60 and 69 years (50.2%).
The majority was white (48.1%), 38% of the elderly were married, 44.3% did not have any school education, 62% were Catholics, 46% had an income
up to one minimum wage, 89% lived with at least
394
Acta Paul Enferm. 2014; 27(5):392-8
one family member and 94.1% had children, as described in table 1.
Regarding the health situation of the elderly, most
had, at least, one non-transmissible chronic disease,
namely, 81% had hypertension, followed by type 2
diabetes mellitus (29%), chronic pain (21%), osteoporosis (18.5%) and osteoarthritis (14%).
Regarding the functional capacity measured
by Katz and Lawton scales for the basic activities
of daily living, partial dependency for one or two
activities reached only 22% of the elderly, with
a functional independent majority (76%) for
those activities. For the instrumental activities,
54% had a partial dependency assessment in at
least one activity performed and 6% were totally
dependent to use transportation, take their medications, take care of their finances, among other
activities (Table 2).
Regarding violence, about 60% reported
having suffered some form of violence at some
point of life, after the age of 60, even with the
highest scores of independence, both in Katz and
Lawton scale. As for the scores of greater functional dependence, i.e., greater need of help in
performing self-care activities and more complex
everyday activities, more than 70% of the elderly
reported some situation of abuse after becoming
elderly (Table 2); however, there was no significant value in the applied tests in terms of the
relationship between variables.
In the analysis of the types of violence, psychological violence was the most prevalent, with
37% being humiliation, insult situations, rudeness, screaming and threatening the elderly, and
24% being discrimination, i.e., abused by not
being treated with respect (Table 3).
Regarding the results of the relation between
functional capacity and the presence of violence,
the only type of violence where there was a value with statistical significance in the test performed concerned the association between basic
activities of daily living and physical violence
(p=0.02). The higher the Katz score, the greater
the chance of the elderly suffering physical violence. In other words, the higher the dependence to perform basic activities, the higher the
Faustino AM, Gandolfi L, Moura LB
Table 1. Characteristics of the elderly and violence
Gender
Variables
Gender
Female
Male
Violence after 60 years
Violence after 60 years
Yes
No
Yes
No
n(%)
n(%)
n(%)
n(%)
60-69
53(68.80)
24(31.20)
24(58.50)
17(41.50)
70-79
46(69.70)
20(30.30)
13(52.00)
12(48.00)
>80
13(59.10)
9(40.90)
5(83.30)
1(16.70)
White
55(65.48)
29(34.52)
18(60.00)
12(40.00)
Brown
41(78.85)
11(21.15)
15(57.69)
11(42.31)
Black
16(55.17)
13(44.83)
9(56.25)
7(43.75)
Uneducated
46(63.89)
26(36.11)
17(51.52)
16(48.48)
1 year
10(71.43)
4(28.57)
4(80.00)
1(20.00)
2-4
30(66.60)
15(33.40)
12(63.10)
7(36.90)
5-8
21(80.70)
5(19.30)
5(50.00)
5(50.00)
>9
5(62.50)
3(37.50)
4(80.00)
1(20.00)
36(76.60)
11(23.40)
24(55.81)
19(44.19)
Age group, years
Color
Education, years
Marital Status
Married
Widowed
44(64.71)
24(35.29)
4(66.67)
2(33.33)
Single
11(57.89)
8(42.11)
4(66.67)
2(33.33)
Lives with a partner
4(57.14)
3(42.86)
3(50.00)
3(50.00)
Divorced or separeted
17(70.83)
7(29.17)
7(63.64)
4(36.36)
70(70.71)
29(29.29)
30(63.83)
17(36.17)
Occupation
Retired
Receives benefits
11(78.57)
3(21.43)
2(66.67)
1(33.33)
Receives pension
12(50.00)
12(50.00)
0(0.00)
1(100.00)
Works
8(72.73)
3(27.27)
5(35.71)
9(64.29)
Receives support from family/others
11(64.71)
6(35.29)
5(71.43)
2(28.57)
Income, minimum wages
Without income
5(100.00)
0(0.00)
1(33.33)
2(66.67)
Until 1
59(66.29)
30(33.71)
8(40.00)
12(60.00)
2-3
40(65.57)
21(34.43)
28(65.12)
15(34.88)
>4
7(87.50)
1(12.50)
2(66.67)
1(33.33)
Does not know exactly/does not have a fixed amount
1(50.00)
1(50.00)
3(100.00)
0(0.00)
Yes
106(69.28)
47(30.72)
41(58.57)
29(41.43)
No
6(50.00)
6(50.00)
1(50.00)
1(50.00)
101(68.20)
47(31.80)
37(60.60)
24(39.40)
Alone
10(62.50)
6(37.50)
5(50.00)
5(50.00)
Accompanied by a non-relative person
1(100.00)
0(0.00)
0(0.00)
1(100.00)
Catholic
66(67.35)
32(32.65)
28(57.14)
21(42.86)
Protestant
41(66.13)
21(33.87)
14(63.64)
8(36.36)
Others
5(100.00)
0(0.00)
0(0.00)
1(100.00)
Children
Accompanied by a relative
Living arrangement
Current religion
n=237
Acta Paul Enferm. 2014; 27(5):392-8
395
Functional capability and violence situations against the elderly
Table 2. Indices of functional capacity and violence situation
Suffered violence
Total
n(%)
p-value
65(36.2)
180(76.0)
0.49
36(67.9)
17(32.1)
53(22.3)
3(75.0)
1(25.0)
4(1.7)
60(63.1)
35(36.9)
95(40.1)
Partially dependent (score between 26-18)
84(65.6)
44(34.4)
128(54.0)
Totally dependent (score <18))
10(71.4)
4(28.6)
14(5.9)
Activities of daily living
Yes
n (%)
No
n(%)
Independent (score =6)
115(63.8)
Partially dependent for 1 or 2 activities (score 7-8)
Partially dependent for 3 or more activities (score ≥9)
Basic activities of daily living
Instrumental activities of daily living
Independent (score =27)
0.31
n=237; Chi-square test (p<0.05)
Table 3. Type/nature of violence and its relationship to functional activities
Positive cases
Negative cases
Lawton Scale
Katz Scale
n(%)
n(%)
p-value
p-value
Humiliation
88(37.13)
149(62.87)
0.60
0.12
Discrimination
57(24.05)
180(75.95)
0.90
0.08
Physical violence
24(10.13)
213(89.87)
0.12
0.02
Sexual violence
10(4.22)
227(95.78)
0.98
0.33
Abandonment
56(23.63)
181(76.37)
0.75
0.89
Negligence
37(15.61)
200(84.39)
0.54
0.73
Financial abuse
52(21.94)
185(78.06)
0.90
0.59
Self-neglect
28(11.81)
209(88.19)
0.71
0.26
Violence type / nature
n=237; Chi-square test (p<0.05)
possibility of the elderly suffering physical violence, when, for example, he/she needs help to
maintain fecal or urinary continence, to change
clothes or to take a bath (Table 3).
Discussion
Although the aim of this study was the association
of the violence phenomenon and the conditions
of functional capacity among the elderly, one of
the study limitations concerns the fact that it was
not possible to establish a cause and effect relation
among the analyzed factors, which suggests that
the event was caused by the association of other
variables that were not the scope of this study, as
violence against the elderly is a multifaceted and
complex phenomenon, with both clinical and
social and situational origins. Thus, the violence
against the elderly comprises several aspects of
nursing care and, therefore, needs to be addressed
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Acta Paul Enferm. 2014; 27(5):392-8
during care in all settings of action of nurses and
other healthcare professionals.
The approaches and methods employed allowed
to verify that, in reality, the assessments of functionality and violence aspects may be performed together, since they complement each other, in order
to contribute to maintain the physical, mental and
social integrity of the elderly, through a global care
to the elderly, provided by nurses and a multiprofessional team.
The sample characterization as for socioeconomic and demographic data and the context of
the elderly corroborated the findings of another
studies, whose elderly inclusion methods were
similar to this study, with a predominance of
elderly women, white, aged between 60 and 70
years old, with low education level and living with
a family member.(3,12-14)
The feminization phenomenon of the elderly population may be observed in several studies
and explained from some striking history facts,
Faustino AM, Gandolfi L, Moura LB
such as the greater longevity reached by women, which may be associated with the increased
health care and the non-exposure, while still
young, to risk situations of violent death − this
occurrence has a higher concentration in men
for this elderly generation.(13,15)
The explanations are based on a perspective
of gender, objectified symbolic spaces and lifestyles in contexts of socio-spacial occupation in
the territories.
A singular feature is that the elderly are living with a family member, a situation denominated by co-residence. Very few live alone, and
this fact is due to possible situations such as the
financial dependence of other family members
− which can characterize financial abuse, since
most of them have their own income, or the inverse, when the elderly are financially dependent
on family members.(16)
Another reality is the concern in caring for elders in the Latin culture, i.e., the behavior of overprotecting the elderly, who, in the symbolic imagery is represented as fragile and dependent of help
to perform activities, from the most complex to
the most basic self-care ones, which reduces their
autonomy and independence still often preserved.
The condition to live with relatives does not guarantee that there will be an adequate care to the needs
of the elderly and is not characterized as a protective
factor against abuse.(17,18)
The comorbidities evidenced by the presence
of chronic diseases among the elderly present similar results to other studies, with hypertension and
diabetes being the most prevalent in this population. These comorbidities are mainly related to
lifelong habits, to the senescent aging process and
to the senility associated, in turn, to endocrine and
cardiovascular diseases, which favor the development of these diseases and the onset of disabling
complications.(3,13,19,20)
The assessment of functional capacity in the
elderly population analyzed in other studies with
young elderly highlighted that, in activities of daily
living, they showed greater functional dependence
in relation to instrumental activities, when assessed,
which can be related to the natural decline typical
of aging. This occurs in most elderly populations
without neurodegenerative diseases.(3,13,19,21)
Regarding violence situations and functional
capacity, it is unanimous among the studies that
an increased level of dependence results in a greater
chance of the elderly being victims of violence, i.e.,
the elderly who need help for self-care or to perform more complex activities of daily living, such as
handling finances, shopping and others, mainly due
to physical disabilities, are at a higher risk of suffering abuse or mistreatment, especially when there is
not a good relationship between the elderly and the
relatives or the caregiver − and this may favor the
occurrence of violence.(16,21,22)
As observed among the studied elderly, although
only physical violence presented a significant result
in the studied model in situations of dependence
for activities of daily living, the other types of violence may be evidenced when there is a certain decline in functions of higher complexity associated
to the presence of cognitive impairment. The reason
for this is that the elderly would be doubly exposed
to conditions of abuse, because he/she is inserted in
a context that signals the loss of autonomy and independence.(16,21-23) In another study, the decrease of
functional capacity among the elderly was associated with episodes of financial and emotional abuse.
(12)
New models of multilevel logistic regression
needs to be tested to reveal possible effects between
other variables.
It should be highlighted that the psychological
violence, followed by abandonment and financial
abuse were the most commonly reported conditions among the respondents. Other studies have
already evidenced that a greater dependence in
functional activities is associated with an increase
in the possibility of the elderly suffering financial
and emotional abuse, since they are more psychologically and physically frail and more vulnerable
to situations involving verbal aggression, abuse
threats, harassment or even intimidation. The detection of this nature of abuse, still poorly reported or notified in our milieu, deserves the attention
of the professionals.(14,16,21)
The use of strategies that enhance the early detection and intervention of nursing and other proActa Paul Enferm. 2014; 27(5):392-8
397
Functional capability and violence situations against the elderly
fessionals towards the families of elderly individuals
who suffer abuse is a need that must be incorporated to the nursing practice, mainly among elderly
populations with risk factures inherent to the normal aging process and those in situations of vulnerability.(24)
Conclusion
Being dependent in basic self-care activities and suffering physical violence were statistically significant,
i.e., when the elderly needs help in performing personal hygiene, transfers, feeding, among others,
there is a greater chance of exposure to situations of
physical abuse.
Collaborations
Faustino AM; Gandolfi L and Moura LBA contributed to the project conception, relevant critical
revision of the intellectual content, research development and data interpretation, drafting and final
approval of the version to be published.
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Acta Paul Enferm. 2014; 27(5):392-8
Original Article
Quality of life of frail elderly
users of the primary care
Qualidade de vida de idoso fragilizado da atenção primária
Maria Helena Lenardt1
Nathalia Hammerschmidt Kolb Carneiro1
Jéssica Albino1
Mariluci Hautsch Willig1
Keywords
Frail elderly; Quality of life; Geriatric
nursing; Primary nursing; Primary
health care; Questionnaires
Descritores
Idoso fragilizado; Qualidade de vida;
Enfermagem geriátrica; Enfermagem
primária; Atenção primária à saúde;
Questionários
Submitted
June 24, 2014
Accepted
June 30, 2014
Abstract
Objective: Identifying the quality of life of frail elderly patients, users of primary care services.
Methods: A cross-sectional, quantitative study. The sample size was calculated based on the estimate of
population proportion and consisted of 203 elderly. Data were collected by using a questionnaire of physical
activity for the elderly, fatigue/exhaustion, quality of life, and by carrying out a test of gait speed, handgrip
strength and anthropometric measurement.
Results: Among the 203 seniors, 39 were fragile. The mean scores for quality of life presented by the frail
elderly were the following: 60.4 for pain, functional capacity 61.1, limitations due to physical aspects 71.1,
general state of health 71.4, vitality 75, mental health 76.4, emotional aspects 81.1 and social aspects 85.6.
Conclusion: The dimensions of quality of life of the frail elderly that had lower mean scores were pain,
functional capacity, limitations due to physical aspects and general state of health.
Resumo
Objetivo: Identificar a qualidade de vida de idosos frágeis usuários da atenção primária.
Métodos: Estudo quantitativo transversal. A amostra foi calculada com base na estimativa da proporção
populacional e constituída por 203 idosos. Os dados foram coletados mediante questionário de nível de
atividade física para idosos, fadiga/exaustão, qualidade de vida e realização de teste de velocidade da marcha,
força de preensão manual e medição antropométrica.
Resultados: Dos 203 idosos, 39 deles eram frágeis. As médias de qualidade de vida apresentadas pelos
idosos frágeis foram: 60,4 para dor, 61,1 capacidade funcional, 71,1 limitações por aspectos físicos, 71,4
estado geral de saúde, 75 vitalidade, 76,4 saúde mental, 81,1 aspectos emocionais e 85,6 aspectos sociais.
Conclusão: As dimensões da qualidade de vida dos idosos frágeis que apresentaram menores médias foram
dor, capacidade funcional, limitações por aspectos físicos e estado geral de saúde.
Corresponding author
Nathalia Hammerschmidt Kolb Carneiro
Quinze de Novembro street, 1299,
Curitiba, PR, Brazil.
Zip Code: 80060-000
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400067
Universidade Federal do Paraná, Curitiba, PR, Brazil.
Conflicts of interest: no conflicts of interest to declare.
1
Acta Paul Enferm. 2014; 27(5):399-404
399
Quality of life of frail elderly users of the primary care
Introduction
The increased longevity of the population causes
people to think more deeply about the aging process and its effects on quality of life. A study with
subjects aged 65 years or more aimed at assessing
the perception of the elderly about their quality
of life, pointed out that the majority considered
‘being healthy’ and ‘not having disabilities’ as the
main definitions of the term.(1) Answers like ‘having
energy’, ‘being happy’ and ‘proper functioning of
the senses’ were also found.(2) Although quality of
life is defined in different ways, there is a consensus
that it is a multidimensional concept that includes
psychological, social, environmental and spiritual
dimensions.(2)
One of the most widely used instruments to assess health-related quality of life is the SF-36 (Medical Outcomes Study 36-Item Short-Form Health
Survey), developed from the Medical Outcomes
Study (MOS), a questionnaire published in English
in the year 1990 that is specific to the elderly population. In Brazil, the SF-36 was translated and validated in a study that examined the quality of life of
individuals with rheumatoid arthritis.(3) According
to the author, it was adapted for use in the Brazilian population considering the local socioeconomic
and cultural conditions.
The SF-36 is a questionnaire of easy application. Because of its reproducibility and validity, the
questionnaire is an additional parameter for assessing the quality of life of individuals with different
pathologies, in research and assistance.(3) One of the
health conditions evaluated in this study and associated with the SF-36 was the syndrome of physical
frailty in older adults.
The syndrome of physical frailty can be defined
as ‘a medical syndrome with multiple causes and
contributions, which is characterized by a diminution of strength, endurance and reduced physiological function that increases the vulnerability of
individuals and develops greater dependence and/
or death’.(4) According to the authors, from this
physical focus, frailty can be evaluated through five
physical components: unintentional weight loss,
reduced grip strength, decreased physical activity,
400
Acta Paul Enferm. 2014; 27(5):399-404
self-reported fatigue and decreased gait speed. Older people who present three or more of these features are considered frail; those with one or two are
pre-frail and those who do not have any of these
components are non-frail seniors.(5)
Although the relations between aging, frailty
and quality of life have been little explored, a recent
number of studies connects the frailty syndrome
with a worsened quality of life.(6,7) Studies evaluating the frailty syndrome through the five physical
components and the quality of life through the SF36, observed that frail elderly had lower scores in
almost all dimensions of quality of life when compared to other participants.(8-10) However, it is not
yet a consensus that the frailty syndrome negatively
influences the quality of life of individuals.
The frail elderly are vulnerable to unhealthy
outcomes and therefore, they can express different combinations of quality of life. Little is known
about the quality of life of Brazilian frail elderly,
about the specific affected aspects, the deficits, the
personal compensations and available resources.
Hence, studies investigating the quality of life associated with frailty are needed. Through the results of these studies it will be possible to support
a more independent life for elderly and to base
preventive actions taken by health professionals,
focusing on aspects related to frailty and quality
of life.(11)
Given the above and the national deficit in studies that assess the frailty syndrome by the physical
phenotype, the objective of this study was identifying the quality of life of frail elderly patients, users
of primary care services.
Methods
This is a quantitative, cross-sectional study carried
out in a Basic Health Unit, which is part of the primary health care service, located in Curitiba, state
of Paraná, southern region of Brazil. The target
population consisted of elderly aged 60 years and
over, in the period between January and April 2013.
The following inclusion criteria were adopted
for the selection of the elderly: a) age equal to or
Lenardt MH, Carneiro NH, Albino J, Willig MH
over 60 years; b) getting a score higher than the
cutoff point (according to the level of education)
in the cognitive test called Mini-Mental State Examination.(12,13) The exclusion criteria were: a) having previous diagnoses of diseases or serious physical and mental deficits that prevented the participation in the stages of interview and assessment of
the frailty phenotype; b) having previously participated in the research.
This was a convenience sample and individuals
were invited to participate in the study according
to their order of arrival in the health service. The
Mini-Mental State Examination was taken in a private environment for tracking the changes in cognitive function (cognitive screening) of the elderly.
(12,13)
In this study was used the validated version
with the following cutoff points: 13 for illiterates,
18 for medium and low education and 26 for high
levels of education.(13) The Mini-Mental State Examination comprises 11 items grouped into seven
categories: temporal orientation, spatial orientation, registration of three words, attention and
calculation, memory of three words, language and
visual construction capacity. The scores range between zero and 30.
Data collection included the assessment of the
frailty syndrome and evaluation of the health related quality of life of the elderly. In order to make
the specificity of elderly Brazilians effective, two
changes were made in the evaluation of measures
of the frailty phenotype. According to American
researchers and their collaborators, the Minnesota
Leisure Activity Questionnaire is applied to identify the level of physical activity. For assessing the
level of energy, specifically for the fatigue/exhaustion component, these authors use two questions
of the Center for Epidemiologic Studies Depression Scale - CES-D.(5) In the present study was
applied the Level of of Physical Activity for the
Elderly CuritibAtiva questionnaire for the physical activity component.(14) The energy level was
known through a question of the Geriatric Depression Scale - GDS, and by a graduated visual
scale, using a numbered rule.(15)
The unintentional weight loss component was
measured by the self-report of weight loss equal to
or greater than 4.5 kg or 5% of body weight within
the last year. The gait speed test was used to measure the slowness in seconds (distance of 4 m) with
adjustment for gender and height. The handgrip
strength was measured with a dynamometer in the
dominant hand with adjustment for gender and
body mass index - BMI.
The Medical Outcomes Study – MOS, Short
Form 36 - SF-36, was used for assessing the health
related quality of life. This is an instrument consisting of 36 questions; a question of comparison
between the current and previous health, and 35
questions classified into eight domains: physical
functioning, role-physical, bodily pain, general
health, vitality, social functioning, role-emotional and mental health. The final score ranges from
zero to 100, with higher scores indicators of positive health perception. The instrument was validated for the Portuguese language and is called
“Brazil - SF-36”.(3)
The sample size was determined based on the
estimate of population proportion. The confidence
level was set at 95% (α = 0.05), 0.12 variance and
sampling error was fixed at five percentage points.
It was added 10% to the sample size, for the possibilities of losses and refusals, resulting in a sampling
plan consisting of 203 elderly.
Data were organized in the Excel® 2007 program
and the EpiInfo version 6.04 was used for statistical
analysis of data: absolute and percentage frequency
distribution, mean and standard deviation.
The development of study followed the national
and international standards of ethics in research involving human beings.
Results
The study included 203 elderly patients, of whom
39 (19.2%) were classified as frail, 115 (56.7%) as
pre-frail and 49 (24.1%) as non-frail.
The highest mean score for quality of life of frail
elderly was for the psychosocial dimensions - concerning social aspects, emotional aspects, vitality
and mental health. The lowest mean score was for
the physical dimensions - concerning pain, funcActa Paul Enferm. 2014; 27(5):399-404
401
Quality of life of frail elderly users of the primary care
tional capacity, limitations due to physical aspects
and general state of health (Table 1).
Table 1. Quality of life of frail elderly
Dimensions of quality of life
Frail elderly
Mean (SD)
Observed variation
Functional capacity
61.1(27.9)
0 – 100
Limitation due to physical aspects
71.1(41.1)
0 – 100
Pain
60.4(30.7)
0 – 100
71.4(17)
32 – 97
75(24.4)
15 – 100
General state of health
Vitality
Social aspects
85.6(25.6)
0 – 100
Emotional aspects
81.1(36.5)
0 – 100
Mental health
76.4(23.4)
20 – 100
The quality of life of frail elderly by position is
shown in chart 1. It is observed that the pain dimension of quality of life is the worst evaluated and
the social aspect dimension is the best evaluated.
Decreased quality of life
Chart 1. Quality of life of frail elderly by position
Dimension position
(from lowest to highest score)
Frail elderly
(score)
1st Position
Pain (60.4)
2 Position
Funtional capacity (61.1)
3 Position
Physical aspects limitations (71.1)
4 Position
General state of health (71.4)
5 Position
Vitality (75)
6 Position
Mental health (76.4)
7 Position
Emotional aspects (81.1)
8th Position
Social aspects (85.6)
nd
rd
th
th
th
th
Discussion
The limits of the study results are related to the
cross-sectional design that does not allow establishing relations of cause and effect. On the other hand,
the results could guide gerontological nursing care
in the practice with frail, pre-frail and non-frail elderly. The studies on the syndrome of frailty and
quality of life of seniors subsidize the provision of
care for successfully combating the frailty, and consequently resulting in improved quality of life for
these individuals.
When compared to national and international
studies, the frequency distribution of frailty in this
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Acta Paul Enferm. 2014; 27(5):399-404
study is significantly high (19.2%). A study with
606 Americans aged 65 years or more, in which 301
participants were of Mexican ancestry and 305 of
European descent, found 12.2% and 7.3% of frail
elderly, respectively.(16) Another study carried out in
Spain with a sample of 814 elderly (aged 65 years
or more), found 10.3% of frail elderly.(17) The pioneering study carried out in Brazil on Frailty in
Brazilian Elderly, consisting of a sample of 3,413
individuals aged 65 years or over, revealed 9.1% of
frail elderly.(18)
The cultural difference is considered a determining factor. Researchers claim that the unequal
distribution of frailty in different places, besides
reflecting possible differences in health between
countries and regions, can also be attributed to the
cultural characteristics that influence the perception
of health and interpretation of subjective items of
the scales used to assess frailty.(19) Issues relating to
lifestyle, nutrition, hydration, presence of comorbidities and medication use may also have influenced the divergence of results.
The dimensions of quality of life of the frail elderly most affected by the frailty syndrome resemble those found in the research conducted with a
sample of 1,008 American elderly of Mexican descent aged 74 years or more.(8) The study on the relation between the frailty syndrome and the quality
of life of older people using the Medical Outcomes
Study - MOS Short Form 36, concluded that the
frail elderly of the sample had lower mean scores in
the aspects of functional capacity, limitations due to
physical aspects and general state of health.
The biological nature of the frailty syndrome itself justifies the significant deficit in the physical dimension of quality of life of frail elderly. In the cycle
of frailty, physical problems such as sarcopenia, multiple diseases, excessive use of medication, and neuroendocrine deregulations are directly related with
frailty and, consequently, affect the quality of life of
these individuals. Moreover, the decline of different
physical components that occurs in the syndrome
may contribute to this result. Studies have shown
that the decrease in physical activity,(20,21) handgrip
strength,(9,10) gait speed(9,10) and energy(2,9) are directly related to decreased quality of life. Identifying the
Lenardt MH, Carneiro NH, Albino J, Willig MH
components of frailty associated with the quality of
life of frail elderly is an important first step, as it will
lead to the early detection of the involved problems
and the establishment of interventions and preventive actions.(11)
Unlike other studies, the dimension of pain had
the lowest mean score of all investigated dimensions
(60.4 points).(8,10) Pain in aging is related to symptoms that are precursors of decline of health and
of bodily functions. Physical changes inherent to
the frailty of the elderly can be associated with a
reduction in health related quality of life, with the
lowest mean scores for the pain dimension of the
SF-36.(9) The early identification of pain and the use
of analgesic drugs may be important factors in the
prevention of frailty and increase in quality of life.
A study shows that physical activity practice can
improve the condition of frailty in the elderly and
therefore, functional capacity.(22) Thus, prescriptions for physical activity according to the possibility of individuals, could act both in the prevention
of frailty syndrome as in improving the quality of
life of frail elderly. Also, engaging in physical activity can improve mental health and promote social
contacts,(20) which is also beneficial for the psychosocial dimensions of the quality of life of seniors.
The psychosocial dimensions have obtained the
best scores in the quality of life of frail elderly, a
result of the social relations maintained by most of
them. The main feature of the psychosocial profile
is to be living with relatives or with the spouse and
not feeling alone. Many Brazilian elderly still have
an important role in the maintenance of themselves
and their families.(20) These factors lead the elderly
to maintain an active social life, reducing isolation,
dependency, thus obtaining better scores on quality
of life regarding the psychosocial dimensions. Risk
factors involving social relations are strongly associated with moderate or severe dependence. Although
the frailty syndrome is a risk factor for dependence,
maintaining social relationships can reduce or postpone this scenario.
A national study carried out with 113 participants aged between 60 and 98 years found that
seniors with a routine concern with their network
of friends and family had better quality of life.(21)
According to the author, the ability of the elderly to
remain active in the society and for their loved ones
transcends the limitations and physical disabilities,
while the inability to alter the physical environment
becomes inefficiency, lack of motivation and lower
levels of quality of life.
Conclusion
The frail elderly had lower mean scores for the physical dimensions of quality of life such as pain, functional capacity, limitations due to physical aspects
and general state of health. The highest mean scores
were obtained in psychosocial dimensions, concerning social aspects, emotional aspects, vitality
and mental health.
Acknowledgements
Research carried out with the Support of Scientific and Technological Development of Paraná –
Fundação Araucária (FA), under protocol number
18239, contract 005/2011.
Collaborations
Lenardt MHL; Carneiro NHK; Albino J and Willig
MH contributed to the project design, analysis and
interpretation of data, drafting the article and critical review of the relevant intellectual content and
final approval of the version to be published.
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2. Molzahn A, Skevington SM, Kalfoss M, Makaroff KS. The importance
of facets of quality of life to older adults: an international investigation.
Qual Life Res. 2010; 19:293-8.
3. Ciconelli RM, Ferraz MB, Santos WS, Meinão IM, Quaresma MR.
[Brazilian-Portuguese version of the SF-36. A reliable and valid quality
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Original Article
Cultural adaptation to Brazil and
psychometric performance of the “EvidenceBased Practice Questionnaire”
Adaptação cultural para o Brasil e desempenho psicométrico
do “Evidence-based Practice Questionnaire”
Karina Rospendowiski1
Neusa Maria Costa Alexandre1
Marilia Estevam Cornélio1
Keywords
Nursing research, Clinical nursing
research, Evidence-based nursing;
Psychometric
Descritores
Pesquisa em enfermagem, Pesquisa
em enfermagem clínica; Enfermagem
baseada em evidências; Psicometria
Submitted
March 12, 2014
Accepted
July 29, 2014
Abstract
Objectives: To culturally adapt the instrument “Evidence-Based Practice Questionnaire” (EBPQ) to the
Portuguese language and assess its psychometric qualities.
Methods: The steps of cultural adaptation of measurement instruments were followed. Reliability was verified
through internal consistency, stability by test-retest, and construct validity by the contrasted groups approach.
Results: High Cronbach’s alpha (0.91 to 0.68) and satisfactory Intraclass Correlation Coefficient (0.90) were
obtained in all domains. In assessing construct validity, significant differences were found between groups of
nurses with different backgrounds.
Conclusion: The steps of cultural adaptation of measurement instruments have been successfully completed.
The Brazilian version obtained presents reliable psychometric properties for its use in this population.
Resumo
Objetivo: adaptar culturalmente o instrumento EBPQ para a língua portuguesa e avaliar suas qualidades
psicométricas.
Métodos: Foram seguidos os passos de adaptação cultural de instrumentos de medida. Foi verificada a
confiabilidade por meio da avaliação da consistência interna e da estabilidade pelo teste-reteste e a validade
de constructo com abordagem de grupos contrastados.
Resultados: Obteve-se Coeficiente Alfa de Cronbach elevado em todos os domínios (0,91 – 0,68) e
Coeficiente de Correlação Intraclasse satisfatório (0,90). Na avaliação da validade de constructo, houve
diferença significativa entre os grupos de enfermeiros com diferentes formações.
Conclusão: As etapas de adaptação cultural de instrumentos de medida foram concluídas com sucesso.
A versão brasileira obtida apresenta propriedades psicométricas confiáveis para a sua utilização nessa
população.
Corresponding author
Karina Rospendowiski
Tessália Vieira de Camargo Avenue,
126, Cidade Universitária “Zeferino
Vaz”, Campinas, SP, Brasil.
Zip Code: 13084-971
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400068
Faculdade de Enfermagem, Universidade Estadual de Campinas, Campinas, SP, Brazil.
Conflicts of Interest: there are no conflicts of interest to declare.
1
Acta Paul Enferm. 2014; 27(5):405-11
405
Cultural adaptation to Brazil and psychometric performance of the “Evidence-Based Practice Questionnaire”
Introduction
Evidence-based practice (EBP) is a technology that
has been gaining popularity with the purpose of
improving clinical effectiveness. Its application involves using the best available clinical evidence on
individual patient care and implies to improve clinical professional knowledge with the most consistent
and reliable scientific findings, resulting from the
advancement of clinical research.(1)
Currently, the process of EBP is implemented
in five steps: 1 formulate a searchable, answerable
question; 2 find the best evidence to answer the
clinical question; 3 appraise the evidence according
to its validity, applicability and impact; 4. integrate
the evidence with clinical expertise, customer values​​
and circumstances and information from the practical context; and 5 evaluate the effectiveness and
efficiency of the information found in the application of steps 1-4 and think about ways to improve
job performance.(2)
In the context of nursing, EBP apparently
emerged with the Cochrane Group, journals such
as the Evidence-Based Nursing and centers such
as the Joanna Briggs Institute for Evidence-Based
Nursing.(3) Evidence-based nursing is defined as
“a problem-solving approach to clinical care that
incorporates use of current best evidence from
well-designed studies, a clinician’s expertise, and
patient values and preferences.(4)
However, in nursing, clinical care seems not to
have been benefited with the production of knowledge. Personal difficulties continue to be observed,
such as motivation and dissemination of scientific
findings, as well as situational difficulties, such as
limited resources and inadequate organization of
time.(1,5-7) In order to be successful, EBP requires individual and organizational strategies that address
factors that interfere in its utilization.(8)
Regarding the production of nursing knowledge
on EBP and its application, various measurement
instruments have been developed to evaluate the
use and the barriers to adoption of EBP.(9)
An evaluation of EBP was proposed in 1998 by
means of the “Evidence-Based Practice Questionnaire” (EBPQ). This instrument was developed in
406
Acta Paul Enferm. 2014; 27(5):405-11
the United Kingdom in order to appraise attitudes,
knowledge and implementation of EBP for physicians and other health care providers.(10) The analysis of the psychometric properties of EBPQ was
subsequently performed in a sample of nurses of
various levels of training and was proved to be a
valid and reliable tool.(11) It is a brief self-administered questionnaire, of easy understanding, which
explores the use of EBP by health professionals in
everyday practice.
This instrument has been used in international research, with the purpose to evaluate practice,
knowledge and attitudes of students and attending
nurses. The results show important information
about adopting EBP among these professionals and
suggest strategies for its dissemination.(12-15)
The EBPQ was recently adapted and validated for the Spanish language, obtaining a reduced
version, however suitable for use in that culture.(13)
This version was used in a study in Spain to diagnose the factors that nurses perceive as facilitators
to EBP.(16)
Considering the lack of instruments in Brazil
for assessing EBP among nurses and the importance
of this information to investigate its application in
clinical care as a tool that provides quality assistance,
the objective of this study is to provide a version of
the Evidence-based Practice Questionnaire (EBPQ)
for the Brazilian population by means of the process
of cultural adaptation, as well as through the evaluation of its measurement properties.
Methods
The Evidence-Based Practice Questionnaire
(EBPQ) consists of 24 items rated on a scale of one
to seven (Likert scale). The score of the instrument
is calculated by adding the response values of each
question, totaling 168 points, with higher scores
indicating more positive attitudes toward EBP. The
scores can be also evaluated by fields, calculating
the arithmetic mean. The items are categorized into
three dimensions:
1.Practice of Evidence-Based Nursing: six questions or 42 points;
Rospendowiski K, Alexandre NM, Cornélio ME
2.Attitudes related to Evidence-Based Practice:
four questions or 28 points;
3.Knowledge and skills associated with Evidence-Based Practice: 14 questions or 98
points.
In the end, the instrument presents questions
related to the characterization of the research subjects regarding sociodemographic and data related
to occupational training, work experience and field
of practice.
In the original study, the instrument had a
Cronbach’s alpha of 0.87 and satisfactory convergent validity (p <0.001).(11)
After the author’s consent, the essential steps of
cultural adaptation were followed, as recommended
by specialized publications, in order to ensure its
quality.(17)
First, an independent translation was performed
by two translators separately. One of the translators
was aware of the goals and concepts involving the
instrument to be translated and the other translator
had no prior knowledge of these concepts and goals.
The two translated versions of the instrument were
confronted by the advisor, researcher and a mediator. After identifying the discrepancies, a single
synthesized version of the instrument was obtained.
Subsequently, the obtained synthesized version
was back-translated into English by two translators
native-speakers of English who had not participated in the first stage, thus obtaining back-translation
1 and back-translation 2. These translators did not
receive information on the concepts and purposes
of the instrument.
After completing the back-translation phase,
a committee composed of seven bilingual participants and nursing research experts consolidated all
versions produced into one single version that was
used in the pre-test. A specific instrument was constructed for the purposes of this assessment containing the versions: original, synthesis of translations
and back-translations. The committee evaluated the
semantic, idiomatic, cultural and conceptual equivalence of each item or question of the EBPQ.
To calculate the level of agreement between
the committee judges the Content Validity Index
(CVI) was used.(18) Was considered satisfactory
an index of agreement equal to or above 90%.(19)
Thus, through the evaluation of the judges committee it is possible to verify the content validity
of the questionnaire.
The Pre-test involved a sample of 30 nurses from
a public hospital. At this stage, the understanding of
the instrument was assessed, identifying questions
or concepts considered difficult to understand.
Nurses that took part in this study were from
a public hospital of a public university located
in upstate São Paulo, Brazil. For data analysis,
subjects were divided into two groups. Group
1 included nurses, students and faculty with a
master’s or doctoral degree, or were doctoral candidates. Group 2 included nurses who had only
completed their graduation and who were not
enrolled in any postgraduate course at the time
of data collection.
Nurses who had a completed or ongoing latu
sensu specialization course were excluded from the
study. Subjects who were on vacation or leave during
the period of data collection were also excluded.
Convenience sampling was performed, thus the
number of subjects in each group were equivalent.
The sample size was obtained by calculating the
sample size for the Cronbach’s alpha, totaling approximately 160 individuals.(20)
Reliability was assessed by internal consistency
and stability. For internal consistency, Cronbach’s
alpha coefficient was used. For stability, assessed by
test-retest, in which the questionnaire was administered on two separate occasions, with an interval of
10 to 15 days, the Intraclass Correlation Coefficient
was used.(21)
The validity of the construct was verified with
the known groups approach to determine the degree to which the instrument demonstrated different scores for groups of each group. It was expected
to find higher scores in the Group 1, consisting of
nurses with a Master’s degree or PhDs, in relation
to nurses who held completed the undergraduate
studies. The validity was evaluated by the non-parametric Mann-Whitney test.
The development of the study met national and
international standards of ethics in research involving human beings.
Acta Paul Enferm. 2014; 27(5):405-11
407
Cultural adaptation to Brazil and psychometric performance of the “Evidence-Based Practice Questionnaire”
Results
Following the judges’ evaluation of semantic-idiomatic, conceptual and cultural equivalences
of the EBPQ, minimal changes related to the
translated terms were suggested, such as replacing the word “persevero” (Portuguese word for
persevere) with “mantenho” (Portuguese word
for maintain).
In the equivalence assessment, agreement
for items 1 and 14 was 57%; item 18, 71% and
85% for items 3, 4, 7, 9, 12, 16, 19, 20, 23, 28
and 29. The suggestions were analyzed in a discussion meeting with the researcher, the advisor,
and the members of the research group on cultural adaptation of measurement instruments.
The agreement rates for all the other items were
above 90%.
The participants of the pre-test were 30
nurses of a public hospital, who performed direct care activities and/or nursing management.
It was found that the average time to complete
the questionnaire was nine minutes, the minimum time was six and the maximum time was
21 minutes.
Seven nurses found it difficult to understand
question 01, in relation to the word “lacuna” (Por-
tuguese word for gap). This difficulty was revised,
and it was decided to add the word “falta” (Portuguese word for lack) as a synonym of the first word,
for better interpretation of the question.
The study included 158 nurses, 81 in Group 1
(nurses with master’s or doctoral degrees) and 77
in Group 2 (public hospital nurses without postgraduate degrees). The subjects were 148 (84%)
women and 10 men (16%), of ages between 23 and
66 years. The time since graduation ranged from
01 to 43 years. In Group 1, most subjects were
from the College of Nursing, 64.2% held a master’s degree, 29.6% a doctoral degree and 6.2% a
postdoctoral degree. In Group 2, all nurses worked
in the public hospital, of which 70 (90.9%) performed direct care activities and 7 (9.0%) were
unit managers (Table 1).
Data description of the Evidence-Based
Practice questionnaire:
The final score for the Evidence-Based Practice and
Clinical Effectiveness scale for nurses was 129.15
for Group 1 (nurses with master’s or doctoral degrees) and 111.24 for Group 2 (public hospital
nurses without postgraduate degrees).
In both groups, the domain with the highest
average score per item was Domain 2 - Attitudes
Table 1. Socio-demographic characterization, according to the division into groups (n = 158)
Variable
Group 1 (n=81)
Group 2 (n=77)
Observed variation
Mean (SD*)
Observed variation
Age
41.4(10.7)
25.0 – 66.0
39.1(10.2)
23.0 – 61.0
0.1368
Time since graduation
18.2(10.5)
3.0 – 43.0
14.1(10.0)
1.0 – 32.0
0.0076
Time in practice
17.5 (10.6)
1.0 – 43.0
12.6(9.9)
1.0 – 30.0
0.0021
Variable
n(%)
n(%)
75(92.6)
73(94.8)
6(7.4)
4(5.2)
Public Hospital
31(38.3)
77(100.0)
College of Nursing
50(61.7)
0(0)
Direct care
15(18.7)
70(90.9)
Management
14(17.5)
7(9.9)
University professor
24(30.0)
0(0)
Student
27(33.7)
0(0)
Gender
Female
Male
Place of work
Position
Education
Undergraduate degree
0(0)
77(100.0)
Master’s degree
52(64.2)
-(-)
Doctoral degree
24(29.6)
-(-)
5(6.2)
-(-)
Postdoctoral degree
* SD - Standard Deviation
408
p-value
Mean (SD*)
Acta Paul Enferm. 2014; 27(5):405-11
Rospendowiski K, Alexandre NM, Cornélio ME
Table 2. Intraclass correlation coefficients (ICC) and confidence intervals (95% CI) (n = 50)
Domains
Number of items
ICC*
IC 95%**
6
0.84
0.74 - 0.91
Attitudes toward EBP
4
0.85
0.75 - 0.91
Knowledge and skills associated to EBP
14
0.86
0.77 - 0.92
24
0.90
0.83 - 0.94
1
Evidence-Based Practice
2
3
Total EBPQ
*ICC – Intraclass correlation coefficients; **CI – Confidence interval of 95%
Table 3. Comparison between the mean scores of the items and the score of the domains
Group 1 (n=81)
Domains
Group 2 (n=77)
Mean (SD*)
Total score
Mean (SD*)
Total score
p-value
1
Evidence-Based Practice
5.38(1.05)
32.31
4.57(1.19)
27.29
2
Attitudes toward EBP
5.92(0.82)
23.68
5.34(1.07)
21.42
0.0004
3
Knowledge and skills associated to EBP
5.23(0.71)
73.16
4.46(0.84)
62.53
<0.0001
5.38(0.71)
129.15
4.64(0.83)
111.24
<0.0001
Total EBPQ
related to EBP (5.92 and 5.35 for Group 1 and
2, respectively), followed by Domain 1 - Evidence-Based Nursing Practice (5.38 and 4.54) and
finally, Domain 3 - Knowledge and Skills (5.22
and 4.46).
Reliability
Internal consistency
Regarding internal consistency, the reliability of
each question in relation to the domain of the instrument was evaluated, first for all subjects (n =
156) and then for each group of nurses.
The instrument presented satisfactory internal
consistency values. In the overall sample, Domain
3 had the highest Cronbach’s alpha (0.92), which
assesses the Knowledge and Skills associated with
EBP. Domain 1, which evaluates EBP among nurses presented Cronbach’s alpha of 0.86. Questions
inquiring attitudes related to EBP (Domain 2) obtained the lowest value (0.68).
Stability (test-retest)
To evaluate the reliability with respect to temporal
stability, a sample of 50 nurses was used.The questionnaire showed high stability for all domains
and for the instrument as a whole (ICC = 0.90)
(Table 2).
The assessment of construct validity by means
of the known groups approach showed that the
subjects in Group 1 (master’s or doctoral degrees)
had significantly higher means compared to those
in Group 2 (undergraduate degree). Consider-
<0.0001
ing the total score of the instrument, Group 1
also showed higher values ​​compared to Group 2.
Thus, it is observed that the instrument was able to
demonstrate differences in scores between known
groups (Table 3).
Discussion
Like other validation studies, the study has limitations with regard to the validity of self-reported
measures, because of the impossibility of adding
direct measures of EBP, such as the observation
of professional practice in accordance with their
research findings. Furthermore, because it is the
first study in Brazil using a measuring instrument
for evaluation of EBP among nurses, other studies
about the EBPQ must be produced in the national reality, to ensure greater validity through other
methodological approaches, the expansion of the
locations, and the expansion of quantity and characteristics of nurses.
However, the analysis of individual and organizational barriers in the incorporation of decision-making in individual care for the patient
through the use of the EBPQ can facilitate the
understanding and the directing of formation of
technological skills necessary for a scientifically
adequate healthcare choice. The study provided
a culturally adapted questionnaire into the Portuguese language, with satisfactory assessment of
validity and reliability, in order to create a tool
for the development and evaluation of the imActa Paul Enferm. 2014; 27(5):405-11
409
Cultural adaptation to Brazil and psychometric performance of the “Evidence-Based Practice Questionnaire”
plementation of EBP in educational programs
or initiatives, and for institutions interested in
acknowledging its use or the knowledge of the
professionals.
The cultural adaptation was performed following the steps recommended by international protocols.(22) In the evaluation made by the committee
of judges, a percentage of agreement (CVI) above
90% was obtained for most items.
The mean scores for domains found in the Brazilian version were similar to the scores of other
studies that used the EBPQ.(23) The study obtained
its highest average score per item in the field related
to opinions and attitudes towards EBP, which shows
good acceptability and positive opinions on the subject among Brazilian nurses. A study conducted with
nurses, of various levels of training, in California also
found the highest average score in this area.(12)
The lowest mean scores were found in the domain related to knowledge and skills associated to
EBP. The items questioned the frequency of literature review and the elaboration of research questions. This corroborates with other studies using
the EBPQ to assess the perceptions of nurses on
the topic.(13)
Regarding the evaluation of the psychometric
properties of EBPQ, this showed high values ​​for internal consistency in the analysis of the instrument
as a whole, with greater accuracy for the domain
of knowledge and skills (0.92), followed by the domain related to the application of EBP (0.86) and,
finally, attitudes (0.68). The Cronbach’s alpha score
for the domain on attitudes is justified by its low
number of items. Similar results were found in international studies and in the original study.(9,12,24)
In the analysis of the reliability through stability, a ICC of 0.90 was obtained for the questionnaire
as a whole, which shows the temporal stability of
the instrument.
The assessment of construct validity indicated
significant differences between groups for the domains of practice, attitudes and knowledge of EBP
(p <0.0001). This result represents that the use of
EBP remains an academic and scientific reality and
that the application of research in the practical field
remains incipient.
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Acta Paul Enferm. 2014; 27(5):405-11
A study found higher EBPQ scores among
nurses with a master’s or doctoral degree, nurse
managers and educators, and lower scores between
the domains of the instrument for nurses that held
only an undergraduate degree. Higher educational
and training levels, such as a master’s degree, tend to
show more satisfactory results in relation to knowledge and use of EBP.(7,13,14,24,25)
After completing the steps necessary to deliver the questionnaire for the Brazilian context, it is
suggested that it can be a useful tool for evaluating educational strategies and for evaluating health
institutions concerned with health care quality. In
addition, the instrument can be used to measure
the personal evaluation of professionals regarding
their practice, awakening critical thinking about the
quality of their practice.
Conclusion
It is concluded that the process of cultural adaptation was performed successfully, and that the
Questionnaire of Evidence-Based Practice and
Clinical Effectiveness presents satisfactory validity
and reliability.
Collaborations
Rospendowiski K contributed to the wording of
article, design and design or analysis and interpretation of data. Alexandre NMC and Cornélio ME
contributed to the relevant critical revision of intellectual content and final approval of the version to
be published.
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Acta Paul Enferm. 2014; 27(5):405-11
411
Original Article
Effectiveness of antiemetics in control
of antineoplastic chemotherapyinduced emesis at home
Efetividade de antieméticos no controle da emese induzida
pela quimioterapia antineoplásica, em domicílio
Marielly Cunha Castro1
Suely Amorim de Araújo1
Thaís Rezende Mendes1
Glauciane Silva Vilarinho1
Maria Angélica Oliveira Mendonça1
Keywords
Vomiting/chemically induced;
Chemotherapy; Antinoeplastics agents/
adverse effects; Antiemetics; Oncology
nursing; Residential treatment
Descritores
Vômito/induzido quimicamente;
Quimioterapia; Antineoplásicos/efeitos
adversos; Antieméticos; Enfermagem
oncológica; Tratamento domiciliar
Submitted
February 27, 2014
Accepted
June 2, 2014
Corresponding author
Maria Angélica Oliveira Mendonça
Pará Avenue, 1720, Uberlândia, MG,
Brazil. Zip Code: 38400-902
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400069
412
Acta Paul Enferm. 2014; 27(5):412-8
Abstract
Objective: Evaluating if antiemetics are effective in the prevention or treatment at home, of chemotherapyinduced emesis.
Methods: In total, were included 42 women with breast cancer in moderately emetogenic chemotherapy,
using dexamethasone/ondansetron before each cycle. The frequency of nausea and vomiting was obtained by
applying the instrument in the pre-chemotherapy period, and 24h, 48h, 72h and 96h after chemotherapy. The
use of antiemetics was considered in accordance with adherence to medical prescription.
Results: All patients (n = 42, 100%) reported emesis at some point. Only five cases (11.9%) were anticipatory.
In the first 24 hours (acute emesis), 38 (90.5%)ayed), emesis was reported by all despite the regular use (n
= 20, 47.6%) or not (n = 22, 52.4%) of antiemetics (ondansetron, dexamethasone and metoclopramide/or
dimenhydrinate).
Conclusion: Antiemetics were not effective in the prevention or treatment at home, of chemotherapy-induced
emesis.
Resumo
Objetivo: Avaliar se antieméticos são eficazes na prevenção ou tratamento da emese induzida pela
quimioterapia antineoplásica, em domicílio.
Métodos: Foram incluídas 42 mulheres com câncer de mama, em quimioterapia moderadamente emetogênica,
submetidas à dexametasona/ondansetrona antes de cada ciclo. A frequência de náuseas e vômitos foi obtida
por instrumento aplicado nos tempos pré-quimioterapia e 24h, 48h, 72h e 96h pós-quimioterapia. O uso de
antieméticos foi considerado conforme adesão à prescrição médica.
Resultados: Todas as pacientes (n=42, 100%) relataram emese em algum momento. Apenas cinco casos
(11,9%) foram antecipatórios. Nas primeiras 24h (emese aguda), 38 (90,5%) apresentaram náuseas
associadas (n=20, 47,6%) ou não (n=18, 42,8%) a vômitos e, após este período (tardio), a emese foi referida
por todas, apesar da utilização regular (n=20, 47,6%) ou não (n=22, 52,4%) de antieméticos (ondansetrona,
dexametasona, metoclopramida e/ou dimenidrinato).
Conclusão: Os antieméticos não foram eficazes na prevenção ou no tratamento da emese induzida pela
quimioterapia, em domicílio.
Universidade Federal de Uberlândia, Uberlândia, MG, Brazil.
Conflicts of interest: no conflicts of interest to declare.
1
Castro MC, Araújo AS, Mendes TR, Vilarinho GS, Mendonça MA
Introduction
Nausea and vomiting can be manifested in a variety of conditions, for example, in cases of drug
poisoning.(1) In cancer chemotherapy, the drugs
used are potent inducers of nausea and vomiting,
which represent the most uncomfortable and
stressful adverse effects in view of the patients
themselves.(2)
Several drugs are used in the prevention and
treatment of chemotherapy-induced emesis. Antagonists of serotonin receptors (5-HT3) such
as ondansetron and granisetron are widely prescribed in hospitals, outpatient clinics and for
use at home.(1) However, despite proven efficacy,
the 5-HT3 antagonists do not show satisfactory
results in about 20 to 30% of patients in antiemetic treatment.(3) In this context, the use of
corticosteroids associated with the 5-HT3 antagonist is recommended, in view of greater efficacy in the control of emesis.(4) Other drugs, such
as metoclopramide hydrochloride and dimenhydrinate have also been used, however, without
clearly defined efficacy.(5)
Despite the introduction of antiemetic drugs
considered effective, such as NK-1 receptor antagonist - aprepitant, an inadequate control of
chemotherapy induced nausea and vomiting
(CINV) is still observed and may persist until about five days after chemotherapy.(3,6) Without effective prophylaxis, prolonged nausea and
vomiting can result in dehydration, electrolyte
imbalance, malnutrition, aspiration pneumonia
and increased rates of hospitalization. Moreover,
these symptoms can be so distressing that end up
affecting the quality of life of patients, leading
them to even stop the treatment. Therefore, the
effective and well tolerated antiemetic therapy is
essential in patients receiving intensive chemotherapy.(7)
Thus, we consider that despite the recommendations made by consensus, the occurrence
of CINV is still common, probably due to the
ineffectiveness of antiemetic drugs or the combination of them. Given this, this study aims to
assess the impact of antiemetic drugs currently
used for the control of emesis in patients with
breast cancer undergoing moderately emetogenic chemotherapy.
Methods
This is an observational, longitudinal study carried
out in the outpatient chemotherapy at the Hospital
do Câncer of the Universidade Federal de Uberlândia, in the state of Minas Gerais, southeastern Brazil, between February and November 2013.
Forty-two women with an initial diagnosis
of breast cancer, regardless of tumor staging and
on chemotherapy treatment (initial or ongoing)
were included. It was a non-probabilistic convenience sample, consecutively drawn until reaching the number of subjects in accordance with
sample size calculation (95% CI and 5% alpha
error II).
All patients were followed for three consecutive cycles of chemotherapy - adriamycin (A) and
cyclophosphamide (C) with or without fluorouracil (AC or FAC, respectively) - totaling 126
evaluated cycles. Immediately before each cycle,
all received the same antiemetic therapy (ondansetron plus dexamethasone) administered intravenously, according to the Brazilian Consensus
of Nausea and Vomiting (Consenso Brasileiro de
Náuseas e Vômitos).(8)
Clinical data were obtained from information
on the medical records of patients, such as age
(years), tumor staging (initial - I, IIa; advanced IIb, III or IV), as well as antiemetics and anticancer
drug (generic name) prescribed to use at home. The
latter information was updated according to ongoing treatment.
The daily monitoring to measure the frequency of nausea and vomiting and the routine use of
antiemetics was initiated before the completion
of each cycle of chemotherapy, and for four days
after the end of it. The survey instrument was developed by the authors, based on the Functional
Living Index of Emesis.(8) The interviews were
conducted before the start of chemo and 24, 48,
72 and 96 hours (days one, two, three and four,
Acta Paul Enferm. 2014; 27(5):412-8
413
Effectiveness of antiemetics in control of antineoplastic chemotherapy-induced emesis at home
respectively) after completion of chemotherapy,
by phone, when patients were already at home.
The instrument was applied for three consecutive cycles of chemotherapy, following this same
procedure.
The emesis was considered anticipatory when
presented prior to the chemotherapy session; acute
when occurring in the first 24 hours after chemotherapy and delayed, when nausea and/or vomiting occurred 24 hours after completion of the
cycle.(9)
In the data analysis, three groups of patients
were formed in accordance with the routine use
of antiemetics at home: (1) Regular: use according to medical prescription, following the prescribed dosage; (2) Irregular: use without obeying the association of antiemetics and/or the
recommended dosage, and (3) Self-medication:
addition of some antiemetic to their everyday
use, as well as using what had been prescribed or
using only the antiemetic that they considered as
the most effective.
Statistical analysis was performed with the use
of Microsoft Office Excel 2007 and the GraphPad Prism 5. The results were expressed in mean ±
standard deviation (±SD) and median with minimum and maximum values or absolute and relative frequencies.
The development of study followed the national
and international standards of ethics in research involving human beings.
Results
In total, were included 42 women with mean age
of (±SD) 48.3 ± 10.1 years, ranging between 29
and 73 years. Breast cancer was diagnosed, mostly
at an advanced stage (n=26, 61.9%). In all cases
there were reports of nausea and/or vomiting at
some point of the chemotherapy treatment, despite the regular use of antiemetics (n=20, 47.6%)
or not (n=22, 52.4%) by 100% of the study population (Table 1).
Considering the time of emesis occurrence, only
five cases (11.9%) were anticipatory. However, in
414
Acta Paul Enferm. 2014; 27(5):412-8
Table 1. Age group, tumor staging, and the occurrence and
treatment of emesis
Variables
Measures or frequencies
Age (years)
Mean ± SD
Median (min - máx)
48.3 ± 10.1
46(29-73)
Tumor staging
Initial+
16(38.1)
Advanced*
26(61.9)
Nauseas and/or vomiting
None**
Only nausea
Only vomiting
Nausea and vomiting
14(33.33)
28(66.7)
Type of nausea and/or vomiting*
Antecipatory
Nausea
Nausea and vomiting
Acute
5(11.9)
4(9.5)
1(2.4)
38(90.5)
Nausea
18(42.8)
Nausea and vomiting
20(47.6)
Delayed
42(100)
Nausea
22(52.4)
Nausea and vomiting
20(47.6)
Routine of use of antiemetics at home
Regular**
20(47.6)
Irregular***
20(47.6)
Self-medication****
2(4.8)
Stages I, IIa; *Stages IIb, III and IV; **No episode of CINV; *Rating of nausea and/or vomiting according
to the time of occurrence, pre (anticipatory emesis) and/or post (acute emesis – first 24h - or delayed –
after 24h) chemoterapy; ** Use of antiemetic in accordance with the prescription, following the prescribed
dose; *** Use of the prescribed antiemetic however, not obeying the association of antiemetics and/or the
recommended dosage; **** Addition of some antiemetic into their routine use, as well as using what had
been prescribed, or using only the antiemetic they considered as the most effective
+
the first 24 hours after chemotherapy, 38 (90.5%)
women had nausea associated with vomiting (n=20,
47.6%) or only nausea (n=18, 42.8%), and after this period, emesis was reported by all patients
(n=42, 100%) (Table 1).
Linking nausea and vomiting with the regularity of use of antiemetics (Table 2) showed that
among the group who regularly followed the prescription (n=20), in almost 100% (n=19, 95%)
emesis occurred in the first 24 hours and continued thereafter (delayed emesis). A similar result was
observed for the groups with irregular use (n=20) or
the self-medication group (n=2), where acute and
delayed emesis occurred in 85% (n=17) and 100%
(n=2) of cases, respectively.
Considering the total of cycles evaluated isolatedly (n = 126), nine antiemetic regimens were
listed according to association among drugs or not:
(A) ondansetron; (B) ondansetron, and dexamethasone; (C) ondansetron, dexamethasone and metoclopramide hydrochloride; (D) metoclopramide
Castro MC, Araújo AS, Mendes TR, Vilarinho GS, Mendonça MA
Table 2. Type of nausea and vomiting according to use of
antiemetics at home
Regular**
(n=20)
n(%)
Irregular***
(n=20)
n(%)
Self-medication
(n=2)
n(%)
Only nausea
-
-
-
Vomiting
-
-
-
Nausea and vomiting
-
-
-
Type of nausea and/or vomiting
or only associated with metoclopramide hydrochloride (n=9, 7.2%). The schemes A and B were the
most frequent (32.5% and 31.7%, respectively)
when compared to the others.
A high occurrence of acute and/or delayed emesis (n = 106, 84.1%) was observed for the different antiemetic regimens. Only two patients reported no use of antiemetics in one of the three
analyzed cycles, and another patient reported not
having used any medication in two consecutive cycles (data not shown in Table 3). For these cases,
were found reports of both the occurrence of emesis (delayed nausea, delayed nausea and vomiting)
as the lack thereof.
Emesis was not observed in 18 (14.3%) cycles of chemotherapy and in the vast majority of
these (n = 16, 88.9%), some antiemetic drug was
used in association with others or not (Table 3).
A total of 12 different women had cycles with no
emetic episodes, of which six (50%) had two cycles without complaints of emesis and the rest (n
= 6, 50%) had only one cycle without complaint.
Despite these reports, it is noteworthy that all patients had nausea and/or vomiting at some point,
and in most cases was used an identical antiemetic
regimen to that prescribed in the cycles without
reports of emetic episodes.
+
Acute
Dealyed
Only nausea
1(5.0)
2(10.0)
-
Only vomiting
-
-
-
Nausea and vomiting
-
1(5.0)
-
Only nausea
7(35.0)
4(20.0)
-
Only vomiting
-
-
-
Acute nausea and delayed NV*
2(10.0)
4(20.0)
1(50.0)
Acute NV and delayed nausea*
3(15.0)
4(20.0)
1(50.0)
Nausea and vomiting
7(35.0)
5(25.0)
-
Acute and delayed
*NV - nausea and vomiting; ** Use of antiemetic in accordance with the prescription, following the
prescribed dose; *** Use of the prescribed antiemetic however, not obeying the association of antiemetics
and/or the recommended dosage; + Addition of some antiemetic into their routine use, as well as using what
had been prescribed, or using only the antiemetic they considered as the most effective; The hyphen (-)
indicates no occurrence for the group
hydrochloride; (E) dexamethasone and metoclopramide hydrochloride; (F) metoclopramide hydrochloride and ondansetron; (G) dexamethasone;
(H) dexamethasone and dimenhydrinate; (I) dimenhydrinate (Table 3).
Ondansetron was used after 94 cycles isolatedly
(n=41, 32.5%) or associated with dexamethasone
(n=40, 31.7%), or together with dexamethasone
and metoclopramide hydrochloride (n=4, 3.2%),
Table 3. Occurrence of emesis and the used antiemetic drug regimens
Schemes
Emesis
No emesis
A**
B***
C****
D+
E+
F+++
G++++
H*****
I******
n(%)
n(%)
n(%)
n(%)
n(%)
n(%)
n(%)
n(%)
n(%)
6(14.6)
6(15.0)
-
-
-
-
3(37.5)
1(33.3)
-
Acute
Nausea
2(4.9)
1(2.5)
-
-
-
-
1(12.5)
1(33.3)
-
Vomiting
-
-
-
-
-
-
-
-
-
NV*
-
1(2.5)
-
-
-
-
-
-
-
Nausea
2(4.9)
6(15.0)
-
-
1(16.7)
1(11.1)
3(37.5)
-
-
Vomiting
-
-
-
-
-
-
-
-
-
2(4.9)
3(7.5)
1(25.0)
2(20.0)
-
1(11.1)
-
-
-
Nausea
13(31.7)
9(22.5)
-
4(40.0)
1(16.7)
2(22.2)
1(12.5)
1(33.3)
-
Vomiting
-
-
-
-
-
-
-
-
-
Delayed
NV*
Acute and delayed
AN e DNV#
2(4.9)
3(7.5)
1(25.0)
2(20.0)
4(66.7)
1(11.1)
-
-
ANV and DN##
7(17.1)
7(17.5)
2(50.0)
2(20.0)
-
1(11.1)
-
-
-
NV*
7(17.1)
4(10.0)
-
-
-
3(33.3)
-
-
1(100)
41(32.5)
40(31.7)
4(3.2)
10(7.9)
6(4.8)
9(7.2)
8(6.3)
3(2.9)
1(0.8)
Total
*Nausea and vomiting; #Acute nausea and delayed nausea and vomiting; ##Acute nausea and vomiting and delayed nausea; **Use of ondansetron only; ***Us e of ondansetron associated with dexamethasone; ****Association
of ondansetron, dexamethasone and metoclopramide hydrochloride; +Use of metoclopramide hydrochloride only; ++Use of metoclopramide hydrochloride associated with dexamethasone; +++Uso de ondansetron associated
with metoclopramide hydrochloride; ++++Use of dexamethasone only; *****Use of dexamethasone associated with dimenhydrinate; ******Use of dimenhydrinate only; The hyphen (-) indicates no occurrence for the group
Acta Paul Enferm. 2014; 27(5):412-8
415
Effectiveness of antiemetics in control of antineoplastic chemotherapy-induced emesis at home
Discussion
The limit of the results of this study is related to the
observational design that does not allow establishing relations of cause and effect.
Nurses acting in oncology should know the chemotherapy drugs used, their possible side effects and
the impact triggered by treatment, to ensure quality
care. Therefore, it is essential showing the oncology
teams about the high incidence of emesis even with
an established antiemetic therapy, in order to help
in the treatment of patients with similar conditions.
Despite the use of antiemetic drugs in specialized services, both in outpatient clinics as at home,
in agreement with the consensus, the control of
these symptoms is not yet satisfactory.(3,6,10) Such
statement was demonstrated in the results of this
study when it was observed that all participants had
nausea with or without vomiting, either pre or post
chemotherapy. A study of 178 American patients
also showed the high occurrence of emesis, since
in their results, 34% and 58% of participants experienced acute and delayed nausea and vomiting,
respectively.(11)
It has been discussed and accepted that the
emetogenic profile of chemotherapy drugs is primarily responsible for the intensity and duration
of emesis.(8) Among the 42 studied patients, all
have experienced emetic episodes, revealing that
despite one of the schemes being composed by fluorouracil, the addition of this chemotherapy drug
did not alter the emetogenic profile of the protocol
(data not shown). It is known that in chemotherapy regimens including more than one drug, the
degree of emetogenicity is given by the combination of the chemotherapy drug with the highest
emetogenic degree, plus the degree of emetogenicity of the other drugs.(9)
The management of emesis, particularly at
the late stage of post chemotherapy, is a challenge.(12) It is known that first-generation 5-HT3
antagonists such as the ondansetron, which is the
drug used in most cycles evaluated in this study,
often fails to adequately control the late symptoms.(10) In addition, other drugs such as metoclopramide hydrochloride at high doses, associ-
416
Acta Paul Enferm. 2014; 27(5):412-8
ated with dexamethasone are less effective than
the use in combination of a 5-HT3 antagonist
and dexamethasone,(13) reinforcing the concept
that antiemetics such as metoclopramide hydrochloride and also dimenhydrinate have low therapeutic index,(8) and there are few reports of use
of this drug. It is noteworthy that all the women interviewed in this study had delayed emesis,
which shows the poor control provided by the
antiemetics used by this population.
It was also observed that the frequency of use
of the prescribed antiemetic did not influence the
control of emesis. However, some studies support
the idea that due to irregular use of prescribed
medication, some patients may not be benefiting from the treatment of prophylaxis.(11) Women
taking the prescribed antiemetics irregularly argued that followed this routine for not having the
habit of using any medication on a regular basis,
for considering it unnecessary in face of the discomfort caused by emesis, and due to side effects
of antiemetics.
Besides the features of chemotherapeutic
agents and routine use of prescribed antiemetic,
factors intrinsic to patients also increase the risks
for developing nausea and vomiting, namely: the
female gender, younger than 50 years, history of
low alcohol consumption, history of nausea and
vomiting in previous chemotherapy treatments,
history of motion sickness, nausea and vomiting
during previous pregnancy.(10,14) In this study, it is
noteworthy that the studied population is comprised of women only, with average age under 50
years, which may be contributing factors to the
high incidence of emesis.
Due to not being adequately controlled, nausea and vomiting affect the quality of life and adherence to the proposed treatment.(7) In another
study, the authors indicated that, without the use
of prophylactic antiemetic therapy, chemotherapy can trigger severe nausea and vomiting, which
can lead patients to wish to stop treatment.(11)
Besides the negative impact on quality of life
and influence on adherence to treatment, emesis
may exert a burden on the health system, generating increased costs, whether with other medicines,
Castro MC, Araújo AS, Mendes TR, Vilarinho GS, Mendonça MA
unscheduled medical consultations, and hospitalizations that may be required.(11)
The goal of antiemetic therapy is the complete prevention of emesis. In this context, adherence to new practices that enable better
control of symptoms becomes necessary. Studies have shown that combinations of new drugs
such as palonosetron (serotonin receptor antagonist of the second generation) and aprepitant
(NK-1 receptor antagonist) can offer a better
protection.(10,11,15)
Apart from drugs, complementary medicines and
integrative practices can be associated with treatment
such as herbal medicines, homeopathy, acupuncture,
relaxation, aromatherapy and others. It is noteworthy
that in addition to having these services provided, patients should be counseled regarding their effectiveness
and encouraged to carry them out.(8)
The nursing consultation is also of great importance. Nurses, as members of a multidisciplinary team, are a facilitating bridge on quality
care and form a channel of communication and
orientation, thus assisting effectively in the control of emesis. These professionals should be able
to identify the risks to which patients are subjected, aiming at planning an assistance focused
on preventing and minimizing these side effects.
The results showed that antiemetics were not
able to prevent or treat chemotherapy-induced emesis, which shows that despite the recommendations
made by consensus, nausea and vomiting remain one
of the most prevalent side effects of chemotherapy.
Given the above, it is necessary to optimize
the treatment with antiemetics, providing new
drugs with proven effectiveness, new forms of
complementary and alternative therapies and the
institution of systematic nursing consultation,
impacting in greater control of emesis and consequently positively influencing the quality of life
of patients.
Conclusion
Antiemetics were not effective in the prevention or
treatment at home, of chemotherapy-induced emesis.
Collaborations
Castro MC; Araújo AS; Mendes TR; Vilarinho GS
and Mendonça MAO declare to have contributed
to the project design, analysis and interpretation
of data, drafting the article, critical revision of the
important intellectual content and final approval of
the version to be published.
References
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Original Article
Cross-cultural adaptation of the primary
health care satisfaction questionnaire
Adaptação transcultural do questionário de satisfação
com os cuidados primários de saúde
Elisabete Pimenta Araujo Paz1
Pedro Miguel Santos Dinis Parreira2
Alexandrina de Jesus Serra Lobo3
Rosilene Rocha Palasson1
Sheila Nascimento Pereira de Farias1
Keywords
Nursing research; Primary care nursing;
Public health nursing; Validation
studies; Consumer satisfaction; Primary
health care
Descritores
Pesquisa em enfermagem;
Enfermagem de atenção primária;
Enfermagem em saúde pública;
Estudos de validação; Satisfação do
usuário; Atenção primária à saúde
Abstract
Objective: To develop the cross-cultural validation and assessment of the psychometric properties of the
Questionnaire about the quality and satisfaction dimensions of patients with primary health care.
Methods: Methodological cultural adaptation and assessment study of the psychometric properties, involving
398 users from a primary care service. The construct validity was verified through principal components factor
analysis and internal consistency assessment as determined by Cronbach’s alpha, using SPSS.
Results: A factorial structure was identified that is equivalent to the original instrument, showing six factors
that explain 70.81% of the total variance. All internal consistency coefficients were higher than 0.84, indicating
appropriate psychometric properties.
Conclusion: The results show that the Brazilian Portuguese version of the instrument is culturally and
linguistically appropriate to assess the satisfaction of users attended in primary care services.
Resumo
Submitted
March 12, 2014
Accepted
July 29, 2014
Corresponding author
Elisabete Pimenta Araujo Paz
Afonso Cavalcanti street, 275,
Rio de Janeiro, RJ, Brazil.
Zip Code: 2011-110
[email protected]
Objetivo: Realizar a validação transcultural e avaliação das propriedades psicométricas do Questionário sobre
as dimensões de qualidade e satisfação de pacientes com cuidados primários de saúde.
Métodos: Estudo metodológico de adaptação cultural e avaliação das propriedades psicométricas com
participação de 398 usuários de uma unidade de atenção primária. A validade de construto foi verificada
através da análise fatorial em componentes principais e avaliação da consistência interna determinada pelo
Alfa de Cronbach com uso do SPSS.
Resultados: Identificou-se estrutura fatorial equivalente ao instrumento original emergindo seis fatores
que explicam 70,81% da variância total. Todos os valores de consistência interna foram superiores a 0,84
denotando propriedades psicométricas adequadas.
Conclusão: Os resultados evidenciam uma adequação cultural e linguística do instrumento na versão em
português do Brasil, mostrando-se adequado para avaliar a satisfação dos usuários atendidos em unidades
primárias de saúde.
Escola de Enfermagem Anna Nery, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.
Escola Superior de Enfermagem de Coimbra, Coimbra, Portugal.
3
Escola Superior de Enfermagem Dr. José Timóteo Montalvão Machado, Chaves, Portugal.
Conflicts of interest: no conflicts of interest to declare.
1
DOI
http://dx.doi.org/10.1590/19820194201400070
2
Acta Paul Enferm. 2014; 27(5):419-26
419
Cross-cultural adaptation of the primary health care satisfaction questionnaire
Introduction
Primary care is the first level of care supply for a
good performance of health systems, and offers care
to people and their most common problems. Studies demonstrate better health and user satisfaction
indicators, besides lower health costs in countries
whose health systems are guided by primary health
care.(1,2)
User satisfaction is considered one of the main
objectives of health services, playing an increasingly relevant role in the assessment and guarantee of health service quality in order to offer,
in the health system, the care that is necessary,
accessible and appropriate to the expectations
of the population that directly uses the public
health service.(2-4)
Different factors influence the satisfaction with
the health service, such as the local culture, the
knowledge about how the service functions, the
professionals’ attitudes towards the users’ demands,
the trust in the health professional, past experiences
in using the service, compliance with one’s needs,
treatment success, among others. Given the subjective and multidimensional nature of satisfaction,
this concept is difficult to operate in function of
expectations and demands the services respond to,
which involve the technical and interpersonal aspects of care. The more satisfied the users are with
the health service, the more receptive they can be
to the professional orientations to improve their
health and choose that service as their reference for
treatment.(4,5)
The instruments used to assess satisfaction
with health services are often insufficient to dimension what they really want to measure, mainly
if the object that is being measures has subjective
characteristics. Reaching a consensus in this area
remains difficult.(6,7)Therefore, the particularities
of the service and clients being assessed should
always be considered, mainly if instruments from
other countries and social realities are used, which
require adaptation to another sociocultural reality.
The cross-cultural validation of instruments permits guaranteeing the validity and reliability of the
adapted instruments, assessing what one intends
420
Acta Paul Enferm. 2014; 27(5):419-26
to discover in another context, culture and age,
and permits the comparison of results with other
populations.(8,9)
This study was aimed at developing the
cross-cultural validation for Brazil of the Portuguese version of the Questionnaire about the
quality and satisfaction dimensions of patients
with primary health care, elaborated by Raposo,
Alves and Duarte.(10)
Methods
Methodological cultural adaptation and assessment study of the psychometric properties of the
Portuguese version of the Questionnaire about
the quality and satisfaction dimensions of patients with primary health care, elaborated by
Raposo, Alves and Duarte.(10) The original version consists of 33 items, organized in five dimensions: health service facilities, administrative
attendance, nursing service, medical care and
care in general, with statements in the form of a
seven-point Likert scale, ranging from 1-I completely disagree; 2-I strongly disagree; 3-I somewhat disagree; 4-I neither agree nor disagree; 5-I
somewhat agree; 6-I strongly agree; to 7-I completely agree.
The study was undertaken at a Family Clinic
in planning area 3.1 of the city of Rio de Janeiro,
in the Brazilian Southeast, located in a region
that has recently gone through a pacification
process, involving the continuing presence of the
military police to eradicate the social conflicts
that were common.
Cross-cultural adaptation
Initially, the authors of the questionnaire were
asked for and granted their authorization for the
development of the validation process and further
use with the Brazilian population. To undertake
the cross-cultural adaptation process, the guidelines
proposed in international(9,11) and Brazilian(12) studies were followed, which include five phases: translation, first consensus version, back-translation, expert committee and pre-test.
Paz EP, Parreira PM, Lobo AJ, Palasson RR, Farias SN
Phase I and Phase II
In the first phase, two independent translations
were elaborated (T1 and T2 of the instrument from
the original language (source language) to Brazilian
Portuguese) by one of the nurse researchers and a
physician, both of whom worked in Primary Health
Care, when possible difficulties were verified to understand words that could be semantically adapted to our context. In addition, the translators were
asked to assess the difficulty of each scale item and,
therefore, a score from zero (very difficult) to ten
(very easy) was elaborated. Words that were biased
or whose meaning was unclear were marked in the
questionnaire, together with proposals for improvement in the Brazilian version, as these words were
not current in Brazil.
Based on the independent translations, a sociologist fluent in Portuguese from Portugal developed
a back-translation, which considered the original
questionnaire, the items that maintained the semantic equivalence of the questions (same meaning), the conceptual equivalence (same concepts in
both cultures) and the simple and direct formulation of the questions. Small changes were made,
in line with the study objectives, and incorporated
into the translators’ suggestions, which resulted in
the consensus version.
equivalence, idiomatic equivalence, experiential
equivalence and conceptual equivalence.
The words or expressions with different meanings were removed or adjusted to reflect in the
translated version the same content as the original
version, leading to the validity of the instrument.
Coarse inconsistencies and/or conceptual translation errors were eliminated and the consensus was
followed, which resulted in a version with a 100%
agreement level. Then, any discrepancies were assessed, homogenizing the formulation based on the
consensus. Examples are the original sentences “By
standard the waiting time to be treated in short”,
changed to “The nurses/physicians respect the service hours”; “The attendance cabinets offer sufficient space”, changed to “The consultation rooms
offer sufficient space”.
Phases III and IV
A panel of specialists (expert committee) compared the original version in Portuguese, the consensus translation to Brazilian Portuguese and the
back-translation to Portuguese from Portugal, including a Brazilian epidemiologist, a Brazilian nurse
researcher who works with the family health strategy, a Portuguese nursing teacher with a Ph.D. who
worked in service management and a Portuguese
nursing teacher who researched on health service
quality and had experience in the use of the original questionnaire. All questions from the consensus
version were analyzed to assess the extent to which
the content of each item reflected the meaning and
content of the original version. The decisions made
followed the proposals by Guillemin,(11) aiming for
equivalence between the original version and the
Brazilian version, considering four areas: semantic
Field Research
The questionnaire was applied by means of an interview to 398 users who complied with the inclusion criteria and attended the Family Health Clinic
with health demands. The interviews took place in
the morning and afternoon shifts, from Mondays
to Fridays, between August 5th and November 28th
2013, before medical or nursing care, or while the
user was waiting for some procedure at the clinic. The average duration of the interviews was 15
minutes and the interviewers were grantees, who
received training for this procedure.
At the start of the data collection, the study
objectives and interview procedures were briefly
presented and the participants’ confidentiality and
anonymity were guaranteed. Then, the Free and Informed Consent Term was read, a compulsory document in research involving human beings, which
Phases V and VI
The consensus version was applied to 20 users from
a family health clinic that was not included in the
study, as the final phase of the cultural adaptation
process. In the pre-test phase, no difficulties were
observed to understand and interpret the questions.
Therefore, the researchers found the re-test unnecessary, immediately moving on to the application of
the consensus version.
Acta Paul Enferm. 2014; 27(5):419-26
421
Cross-cultural adaptation of the primary health care satisfaction questionnaire
contained detailed information about the research
phases, methods, possible risks for the participants
and conducts to avoid them. The understanding of
its content and the signature guarantee the participants’ autonomy, in compliance with the ethical
principles of research.
The data were organized in a database and the
statistical analyses were developed in the software
Statistical Package for the Social Sciences version
20.0, including descriptive and trend analyses. To
analyze the internal consistency, that is, the extent
to which all items measure the same construct of
the scale, Cronbach’s Alpha was used.
The development of this study complied with
the Brazilian and international ethical standards for
research involving human beings.
Results
Characteristics of respondents
The sample consisted of 74.1% female and
25.9% male respondents. The mean age was 41
years, with a standard deviation of 15.72 years,
ranging between 18 and 84 years. As regards the
self-referred skin color/race, 48.6% are mulatto,
28% black, 21.2% white and 1.5% indigenous.
9.3% live alone. Among the interviewees, 36.7%
had finished the second cycle of secondary education (5th to 9th grade) and 24.6% the first cycle
of secondary education (1st to 4th grade). In the
interviewed sample, 55.8% did not inform any
formal job.
In terms of monthly income in minimum wages, 38.4% receive between 1 and 2 wages, 32.4%
gained no income and 11.8% informed gaining
some kind of financial aid from the government.
Concerning how frequently they tend to visit the
health service, 35.5% informed 2 to 6 times per
year, 25.6% once per month and 12.7% weekly,
with 59.7% informing routine consultation as the
reason to visit the service.
As regards the satisfaction with the location of
the service, 93.7% are satisfied or highly satisfied,
but 5.3% of the users experience difficulties to reach
the health service, 72.9% take up to 15 minutes to
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Acta Paul Enferm. 2014; 27(5):419-26
reach the service and 94.2% do not spend anything
on transportation.
Only 17.1% of the users are able to schedule
an appointment on the same day, 29.2% take between 2 and 4 weeks to get a medical appointment
and 28.4% between 1 and 2 months. As regards the
delay in the waiting room to consult the physician,
58.8% are attended within the first hour and 15.2%
wait more than 2 hours for this consultation.
Concerning the delay to get a nursing consultation, 35.9% of the users manage this on the
same day. Although 74.9% got the nursing consultation within 30 days, 25.1% informed waiting between 1 and 6 months. 42.4% informed
waiting up to 30 minutes at the waiting room for
the nursing consultation.
In the analysis of the user satisfaction scale, first,
the scale items were assessed according to the dispersion of the answers, showing that the users’ assessment were distributed across all agreement levels, indicating an appropriate discriminatory power
of the items (Table 1). The scores tend to be much
higher than the midpoint of the scale, indicating
the users’ global satisfaction.
The questions with the lowest mean scores are
related to the mean waiting time to get medical and
nursing care. In addition, the mean score of 4.85 is
observed for the question “This health service borders closely on a perfect health service”, indicating
that, although the users feel satisfied, they acknowledge that the service does not fully attend to their
expectations.
Construct validity
The construct validity of a concept like satisfaction,
which is constantly changing and evolving, besides
its subjectivity, although complex, shows to be decisive in order to be considered a measure of credibility. The dimensionality of the instrument was
assessed by means of principal components factor
analysis (PCA), followed by the internal consistency assessment using Cronbach’s Alpha and the
item-factor correlations. In the interpretation of the
factor, a minimum factor loading of ±0.30 was set
for the PCA. The number of factors with an eigen-
Paz EP, Parreira PM, Lobo AJ, Palasson RR, Farias SN
Table 1. Minimum, maximum, mean and standard deviation of the items in the primary health care user satisfaction questionnaire
N=398
Item
Variables of Satisfaction Scale
Minimum
Maximum
Mean
Standard Deviation
1
Facilities look good
1
7
6.25
1.06
2
Temperature in the facilities is pleasant
1
7
6.06
1.31
3
Facilities are comfortable
1
7
6.13
1.12
4
Facilities are clean
1
7
6.30
1.02
5
Bathrooms are in good hygienic conditions
1
7
5.99
1.23
6
There is sufficient space in the consultation rooms
1
7
6.21
1.16
7
The facilities at the clinic are appropriate for disabled people
1
7
5.63
1.59
8
The services are well signaled
1
7
5.99
1.37
9
The functioning hours are appropriate to your needs
1
7
5.70
1.66
10
At this clinic, there is information about health care
1
7
5.72
1.67
11
The Community Agents are thoughtful
1
7
6.05
1.39
12
The Community Agents take interest in your problems and their solution
1
7
5.85
1.52
13
The Community Agents clearly explain what you have to do
1
7
5.94
1.51
14
One normally waits little to be attended
1
7
5.11
1.80
15
The nurses are thoughtful
1
7
6.11
1.24
16
The nurses take interest in your problems and their solution
1
7
5.94
1.35
17
The nurses do everything they can to solve your problem
1
7
5.87
1.49
18
The nurses clearly explain the treatment you will have to do
1
7
5.97
1.43
19
The nurses are competent in the treatments they give you
1
7
6.01
1.42
20
Normally the nurse is available to treat you
1
7
5.60
1.62
21
The nurses respect the functioning hours
1
7
5.20
1.73
22
Normally, one waits little to be attended
1
7
4.61
1.87
23
The physicians are thoughtful
1
7
6.40
1.15
24
The physicians take interest in your problems and their solution
1
7
6.36
1.15
25
The physicians clearly explain the treatments you will have to get
1
7
6.41
1.12
26
The physicians do everything they can to solve your problem
1
7
6.26
1.26
27
The physicians are competent in the treatments they give you
1
7
6.29
1.27
28
The physicians respect the functioning hours
1
7
5.48
1.79
29
One normally waits little to be attended
1
7
4.76
1.88
30
In general, you feel satisfied with the service at this health unit
1
7
5.70
1.55
31
This health unit corresponds to your needs
1
7
5.70
1.52
32
This health service attends to your expectations
1
7
5.38
1.68
33
This health service is very close to a perfect health service
1
7
4.85
1.85
value superior to one and Cattell’s Scree test determined the number of factors for extraction.
The principal components factor analysis resulted in six factors. The matrix produced evidenced a Kaiser Meyer-Olkin (KMO) coefficient
of .919 with significance for Bartlett’s test of
sphericity (BTS) (c2=11171.324, p=.000), indicating the appropriateness of the sample and the
correlation matrix for the factoring. The analysis
revealed six factors with an eigenvalue superior
to 1, which explain 70.82 % of the variance, respectively 20.31% for the first factor, 12.72%
for the second factor, 12.57% for the third factor, 10.58% for the fourth factor, 9.43% for the
fifth factor and 5.20% for the sixth factor. Some
small changes in relation to the original scale
were observed, which nevertheless did not undermine any of the factors.
Concerning the characteristics of the original
and adapted factors (Table 2), these were organized in F1-Nursing Care; F2-Medical Care; F3Health Service Facilities; F4-Global Satisfaction;
F5-Administrative Attendance; F6-Medical Care:
Time and waiting time. The mean and standard
deviation for each of the factors were, respectively:
F1- 1.26 and 5.69; F2- 6.35 and 1.06; F3- 6.04
and 086; F4- 1.37 and 5.48; F5-5.73 and 1.34;
F6-1.70 and 5.12.
The factor “Medical Care” in the original scale
was divided in two factors, the first was called “F2Medical Care”, which groups aspects like the interest in the problems and their solution, the explanation of the treatment needed, the attention and
competency of the professional to solve the problems the user presented during the consultation.
The second factor, called “F6- Medical Care: Time
Acta Paul Enferm. 2014; 27(5):419-26
423
Cross-cultural adaptation of the primary health care satisfaction questionnaire
and waiting time”, refers to aspects related to the
waiting time and the physicians’ compliance with
the time of the appointment. A slight factorial bias
is observed, with scores bordering on 0.30 for the
question “At this clinic there is information about
health care”. It shows a higher saturation level in F4
- “Global Satisfaction” than in F3- “Health Service
Facilities” though, grouping questions about the users’ expectation and satisfaction.
Reliability
The trust in the permanence of the results across
several applications of a certain scale or test, always
associated with an error that needs to be reduced, is
called reliability. For this purpose, the internal consistency method is adopted, obtained through the
mean correlation between all items and the final test
score or factor in question, considering the component items. Cronbach’s Alpha is the most used test
when the items are non-dichotomous and serves as
a good reliability estimate in most situations.
As a reference point, 0.80 is considered, although coefficients of 0.60 or higher are
acceptable when the number of items is small.
The results showed that all factors showed internal
consistency coefficients superior to 0.88, demonstrating that the instrument is reliable, like the
original instrument.
Table 2. User satisfaction: Percentage of explained variance, factorial saturations, commonalities (h²) and internal consistencies per
factor
Factors, % explained variance and commonalities
Item
Scale variables the level of satisfaction
F1
20.31%
F2
12.72%
F3
12.57%
F4
10.58%
F5
9.43%
F6
5.20%
h2
17
The nurses do everything they can to solve your problem
0.908
0.911
18
The nurses clearly explain the treatment you will have to do
0.900
0.896
19
The nurses are competent in the treatments they give you
0.899
0.905
16
The nurses take interest in your problems and their solution
0.891
0.861
15
The nurses are thoughtful
0.885
0.860
20
Normally the nurse is available to treat you
0.883
0.858
21
The nurses respect the functioning hours
0.847
0.846
22
Normally, one waits little to be attended
0.798
24
The physicians take interest in your problems and their solution
0.768
0.857
0.858
25
The physicians clearly explain the treatments you will have to get
0.807
0.786
23
The physicians are thoughtful
0.799
0.775
26
The physicians do everything they can to solve your problem
0.798
0.801
27
The physicians are competent in the treatments they give you
0.774
0.753
3
Facilities are comfortable
0.718
0.591
4
Facilities are clean
0.690
0.536
1
Facilities look good
0.658
0.490
2
Temperature in the facilities is pleasant
0.641
0.446
5
Bathrooms are in good hygienic conditions
0.618
0.489
6
There is sufficient space in the consultation rooms
0.582
0.491
7
The facilities at the clinic are appropriate for disabled people
0.578
8
The services are well signaled
0.488
9
The functioning hours are appropriate to your needs
31
This health unit corresponds to your needs
0.306
0.451
0.317
0.470
0.367
0.307
0.411
0.814
0.823
32
This health service attends to your expectations
0.782
0.824
30
In general, you feel satisfied with the service at this health unit
0.773
0.797
33
This health service is very close to a perfect health service
10
At this clinic, there is information about health care
0,.15
0.734
0.717
0.333
0.335
12
The Community Agents take interest in your problems and their solution
0.879
0.802
11
The Community Agents are thoughtful
0.862
0.871
13
The Community Agents clearly explain what you have to do
14
One normally waits little to be attended
29
One normally waits little to be attended
28
The physicians respect the functioning hours
Cronbach’s Alpha
0.390
0.815
0.802
0.604
0.593
0.349
0.94*
0.94*
0.84*
0.91*
0.88*
0.96*
0.94*
0.93*
0.94*
0.93*
0.809
0.821
0.753
0.815
0.84*
F1-Nursing Care; F2-Medical Care; F3-Health Service Facilities; F4-Global Satisfaction; F5-Administrative Attendance; F6-Medical Care (Time and waiting time); *Scores obtained in this research; ** Scores obtained by
Raposo, Alves and Duarte (2009)
424
Acta Paul Enferm. 2014; 27(5):419-26
Paz EP, Parreira PM, Lobo AJ, Palasson RR, Farias SN
In addition, coefficients superior to the midpoint of the scale are found, highlighting a higher
satisfaction level in Factor 2 “Medical Care” and a
lower satisfaction level in Factor 6- “Medical Care:
Time and waiting time”, considering the time and
waiting time for medical care.
Correlation study
The validity of the items, assessed using Pearson’s
item/factors correlation, with and without overlapping of the item, Pearson’s two-tailed r correlations
between the factors and the principal components
analysis are displayed in table 3.
All items show higher correlation coefficients
without overlapping with the dimension they theoretically belong to than with other dimensions, sugTable 3. Correlações entre os itens e os fatores com e sem
sobreposição
Item
Without overlapping
of the item
F1
F2
F3
F4
F5
F6
p15
0.785
0.824 0.625 0.588 0.452 0.284
p16
0.823
0.859 0.635 0.563 0.514 0.330
0.428
0.434
p17
0.865
0.896 0.670 0.558 0.530 0.351
0.399
p18
0.840
0.875 0.675 0.543 0.509 0.365
0.406
p19
0.861
0.891 0.679 0.566 0.596 0.439
0.423
p20
0.815
0.860 0.572 0.551 0.586 0.366
0.468
p21
0.765
0.825 0.527 0.490 0.563 0.351
0.642
0.622
p22
0.660
0.747 0.460 0.480 0.552 0.387
p23
0.859
0.653 0.903 0.477 0.492 0.371
0.459
p24
0.890
0.622 0.925 0.464 0.494 0.340
0.471
p25
0.830
0.595 0.880 0.429 0.507 0.338
0.502
p26
0.846
0.623 0.897 0.424 0.549 0.396
0.478
p27
0.818
0.635 0.878 0.459 0.509 0.435
0.466
p1
0.528
0.374 0.308 0.612 0.292 0.263
0.226
p2
0.533
0.388 0.304 0.637 0.299 0.236
0.266
p3
0.631
0.415 0.289 0.705 0.388 0.230
0.300
0.267
p4
0.616
0.389 0.290 0.686 0.377 0.323
p5
0.625
0.448 0.340 0.709 0.386 0.362
0.320
p6
0.591
0.485 0.446 0.676 0.408 0.347
0.299
p7
0.626
0.483 0.324 0.733 0.440 0.343
0.305
p8
0.521
0.494 0.327 0.633 0.408 0.354
0.280
p9
0.523
0.468 0.435 0.656 0.475 0.327
0.340
P10
0.498
0.443 0.345 0.442 0.642 0.396
0.320
0.447
P30
0.792
0.604 0.519 0.494 0.857 0.557
P31
0.818
0.547 0.530 0.473 0.875 0.505
0.486
P32
0.855
0.578 0.535 0.527 0.905 0.506
0.582
P33
0.773
0.464 0.434 0.429 0.856 0.469
0.535
P11
0.776
0.313 0.298 0.360 0.433 0.852
0.185
P12
0.849
0.325 0.331 0.442 0.506 0.906
0.280
P13
0.817
0.444 0.472 0.411 0.515 0.885
0.317
P14
0.679
0.390 0.385 0.399 0.561 0.810
0.392
P28
0.834
0.547 0.524 0.382 0.518 0.297
0.925
P29
0.841
0.540 0.465 0.415 0.559 0.370
0.932
*Coefficients obtained in this research; ** Coefficients obtained by Raposo, Alves and Duarte (2009)
gesting interdependence among factors, showing that
the scale represents the factors of user satisfaction and
possesses sufficient familiarity to constitute distinct
dimensions (discriminant convergent validity). The
correlations are stronger with the factor/dimension
they theoretically belong to than with others, complementing the homogeneity of the content of the
items inside each factor/dimension. It is highlighted
that, globally, the coefficients are superior to 0.70, except for items 1,2,6,8,9 and 10 (0.528; 0.533; 0.591;
0.521 and 0.523, respectively).
Discussion
In this study, the five phases of the cross-cultural
adaptation process were described that contributed to the validation for Brazilian Portuguese of the
Questionnaire about the quality and patient satisfaction dimensions with primary health care. An
instrument was produced that is equivalent to the
Portuguese version for use in Brazil, guaranteeing
its idiomatic and semantic equivalence. The assessment of the instrument’s psychometric properties
through the construct validity study showed that
the questions addressed in the instrument measure
what they were intended to measure. The internal
consistency determined by Cronbach’s Alpha, superior to 0.84 for all dimensions, indicated the high
level of reliability of the instrument, as found in
other studies that used psychometrics to measure
subjective phenomena that involve behaviors and
service assessment.(13-18)
For the nurses, using an instrument that assesses
the satisfaction with their individual and team work
contributes to gain knowledge on the impact of
their activities, leading to the adaptation of actions
and enhancing their social visibility in the primary
care context, adopting continuous quality improvement and communication strategies with a view to
care effectiveness.
Globally, the analysis of each item’s correlation
with the factors showed that each items is more
strongly correlated with the factor it belongs to
that with other factors, as a sign of validity.(14,15)
Despite showing higher mean values in all dimenActa Paul Enferm. 2014; 27(5):419-26
425
Cross-cultural adaptation of the primary health care satisfaction questionnaire
sions, the results show lower mean values in the
dimension Medical Care: time and waiting time,
which contributes to a negative assessment of the
health service.
The choice to hold the interviews at the clinic to
facilitate the users’ participation, mainly considering
the low education level of the population who uses
the health service, with possible difficulties to read
the questions, may have caused a bias due to the sole
participation of users present at the health service,
influencing the participants’ response pattern, which
represents a limitation in the assessment of the results.
Conclusion
The instrument Primary Health Care User Satisfaction, in the phases of the cross-cultural adaptation
process of its version translated to Brazil, showed
to be appropriate in psychometric terms, balanced
and effective for use in primary care services, such
as family health services, and demonstrates equivalence with the original version from Portugal.
Collaborations
Paz EPA; Parreira PMSD; Lobo AJS; Palasson RR
and Farias SNP declare that they contributed to
the conception of the project, analysis and interpretation of the data, writing of the paper, relevant
critical review of the intellectual content and final
approval of the version for publication.
References
1. Nascimento AP, Santos LF, Carnut L. [Primary health care via family
strategy in unified health system: introduction to the problems inherent
in the operation of their actions]. J Manag Prim Health Care. 2011;2
(1):18-24. Portuguese.
2. Cruz A. [Primary health care in Brazil: the challenges to enhance the
gateway SUS for brazilians]. Consensus. 2008;35:4-9. Portuguese.
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3. Felismina M, Mantovani MF, Gemito ML, Lopes MJ. [User satisfaction
with primary health care]. Rev Enf Ref. 2013;3(9):17-25. Portuguese.
4. Brito TA, Jesus CS, Fernandes MH. [Factors associated with user
satisfaction in physical therapy services]. Rev Baiana Saúde Pública.
2012; 36(2):514-26. Portuguese.
5. Rosa RB, Pelegrini AH, Lima MA. [Problem-solving capacity of
assistance and users’ satisfaction of the Family Health Strategy]. Rev
Gaúcha Enferm. 2011;32(2):345-51. Portuguese.
6. Esperidião MA, Trad LA. [Evaluation of user satisfaction]. Cênc Saúde
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8. Gjersing L, Caplehorn JR, Clausen T. Cross-cultural adaptation
of research instruments: language, setting, time and statistical
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9. Beaton DE, Bombardier C; Guillemin F, Ferraz MB. Recommendations
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Measures. 2th ed. Toronto: Institute for Work & Health; 2007.
10.Raposo ML, Alves HM, Duarte PA. Dimensions of service quality and
satisfaction in healthcare: a pacient’s satisfaction index. Serv Bus.
2009;3:85-100.
11.Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of
health-related quality of life measures: literature review and proposed
guidelines. J Clin Epidemiol. 1993;46(12):1417-32.
12.Reichenheim ME, Moraes CL. [Operationalization of cross-cultural
adaptation of measurement instruments in epidemiology]. Rev Saúde
Pública. 2007;41(4):665-73. Portuguese.
13. Amaral AC, Cordás TA, Conti MA, Ferreira ME. Semantic equivalence
and internal consistency of the brazilian portuguese version of the
Social Attitudes Towards Appearance Questionnaire-3 (SATAQ-3). Bull
World Health Organ. 2011;27(8):1487-97.
14.Teixeira PC, Hearst N, Matsudo SM, Cordás TA, Conti MA. [Cross-cultural
adaptation: translation and validation of the Brazilian version of Content
Commitment Exercise Scale]. Rev Psiq Clín. 2011;38(1):24-8. Portuguese.
15.Bandeira M, Silva M A. Satisfaction [Scale for Patients with Mental
Health Services ( SATIS - BR ): validation study]. J Bras Psiquiatr.2012;
61(3):124-32. Portuguese.
16.Melo RC, Silva MJ, Parreira PM, Ferreira MM. [Helping relationship
skills in nurses: the validation of a measurement instrument]. Rev Esc
Enferm USP. 2011; 45(6):1387-95. Portuguese.
17.Paschoalin HC, Griep RH, Lisboa MT, Mello DC. [Transcultural
adaptation and validation of the Stanford Presenteeism Scale for the
evaluation of presenteeism for Brazilian Portuguese]. Rev Latinoam
Enferm.2013;21(1):388-95. Portuguese.
18. Salmerón RJ, Iglésias-Ferreira P, García DP, Mateus-Santos H, MartínezMartínez F. [Cross-cultural adaptation to the European Portuguese of
the questionnaire “Patient Knowledge about their Medications” (CPMES-ES)]. Ciênc Saúde Pública. 2013;18(12): 3633-44. Portuguese.
Original Article
Biopsychosocial aspects and the
complexity of care of hospitalized elderly
Aspectos biopsicossociais e a complexidade
assistencial de idosos hospitalizados
Beatriz Aparecida Ozello Gutierrez1
Henrique Salmazo da Silva2
Helena Eri Shimizu3
Keywords
Nursing care; Geriatric nursing; Nursing
service, Hospital; Aged
Descritores
Cuidados de Enfermagem; Enfermagem
geriátrica; Serviço Hospitalar de
Enfermagem; Hospital; Idoso
Submitted
27 February 2014
Accepted
29 July 2014
Corresponding author
Beatriz Aparecida Ozello Gutierrez
Arlindo Béttio Avenue, 1000, São Paulo,
SP, Brazil. Zip Code: 03828-000
[email protected]
Abstract
Objective: To investigate the biopsychosocial aspects and aspects of the health system of hospitalized elderly
and to classify their degree of care complexity.
Methods: This was a quantitative study whose convenience sample consisted of 279 elderly. The
Interdisciplinary Medicine Instrument (INTERMED) method was used, a tool that identified biopsychosocial
aspects and conditions of the health system and classified the complexity of the patient. The data were
submitted to descriptive analysis.
Results: The prevailing profile was of elderly women, retired, white, with low educational levels, married
and satisfied with their life conditions. The mean age was 72.3 years. The biological domain was the most
compromised. As for the complexity of care, 34.8% of the patients required multiprofessional care.
Conclusion: The elderly had high care complexity, with the biological and health system domains being the
most compromised.
Resumo
Objetivos: Conhecer os aspectos biopsicossociais e as condições do sistema de saúde de idosos hospitalizados
e classificar o grau de complexidade assistencial.
Métodos: Trata-se de estudo quantitativo, cuja amostra por conveniência foi constituída por 279 idosos.
Utilizou-se o método Interdisciplinary Medicine Instrument (INTERMED), ferramenta que identifica aspectos
biopsicossociais e condições do sistema de saúde e classifica a complexidade do paciente. Os dados foram
submetidos à análise descritiva.
Resultados: Predominou idosos do gênero feminino, aposentados, de cor branca, baixa escolaridade,
casados e satisfeitos com as condições de saúde. A média de idade foi 72,3 anos. O domínio biológico foi
o mais comprometido. Quanto à complexidade assistencial, 34,8 % dos pacientes requerem assistência
multiprofissional.
Conclusão: Os idosos apresentaram elevada complexidade assistencial, com maior comprometimento nos
domínios biológico e sistema de saúde.
Escola de Artes, Ciências e Humanidades, Universidade de São Paulo, São Paulo, SP, Brazil.
Faculdade de Saúde Pública, Universidade de São Paulo, São Paulo, SP, Brazil.
3
Universidade Federal de Brasília, Brasília, DF, Brazil.
Conflicts of interest: there are no conflicts of interest to declare.
1
DOI
http://dx.doi.org/10.1590/19820194201400071
2
Acta Paul Enferm. 2014; 27(5):427-33
427
Biopsychosocial aspects and the complexity of care of hospitalized elderly
Introduction
The management of elderly care has been the subject
of discussions between professionals, managers and researchers in the field of aging. The literature indicates
that the elderly, especially the oldest and most dependent, require long-term care and assessment of their
biopsychosocial needs in the short, medium and long
term, in order to prevent adverse health outcomes:
falls, insufficient care, disability, institutionalization,
recurrent hospitalizations, and death.(1-3)
In the last two decades, some researchers have
conducted studies in order to identify aggravating
factors in the health/disease status of the hospitalized patients, to improve the quality of care provided to them and also to reduce costs.(4-6)
In this context, one of the proposals that can
be a tool to improve communication within the interdisciplinary team, and to characterize the complexity of care for clinical, scientific and educational
purposes, is the Interdisciplinary Medicine Instrument (INTERMED): a tool that can offer positive
responses in assessing patients requiring care, and
in helping adjust the provision of health services in
general, and in mental health.(7) The validity of this
instrument is documented for the care of several
types of patients.(8-10)
Compared with usual care, targeted nursing
interventions based on the INTERMED scores
resulted in improvements in quality of life, at the
time of admission and discharge in patients in general practice and in elderly patients requiring interdisciplinary care.(6,8-11)
Assuming the importance of providing comprehensive care to the hospitalized elderly, this study
aims to investigate biopsychosocial aspects of hospitalized elderly, and aspects of the health system, and
to classify their degree of care complexity.
Methods
This was a quantitative, descriptive, cross-sectional
study performed in the medical clinic at the University Hospital, São Paulo University, São Paulo state,
in southeastern Brazil.
428
Acta Paul Enferm. 2014; 27(5):427-33
The population consisted of elderly patients admitted to the unit who met the following inclusion
criteria: age 60 years or older, ability to understand
and respond to the interview at the time of data collection. The convenience sample consisted of 279
elderly.
For participant characterization, demographic
data were investigated (name, gender, age, occupation, ethnicity, income, marital status and family
life), as well as one question related to the assessment of self-perceived health status.
For data collection, the INTERMED method
was used, a tool based on data from medical records
and on a semi-structured interview with the patient, which is designed by an analysis of data on
the biological aspects, information on care related
to psychosocial aspects, and on the health system.(7)
This method classified the data into four domains related to biopsychosocial aspects and to the
system used for health care/disease. Each domain
had five variables related to “history”, “current
state” and “prognosis”. The resulting twenty variables were classified from 0 to 3. The sum of these
variables resulted in a score that could range from
0 to 60, indicating the complexity of patient care.(7)
In this study, patients were classified through
INTERMED as “complex” and “non-complex”
based on a cutoff point of 20 representing the need
for integrated treatment.(10,11)
The INTERMED had advantages over other instruments because it was quick to administer, with
an average duration between 15 and 20 minutes.
It explored many pieces of patient data, providing
knowledge and current, historical, and future assessment of four aspects - biological, psychological,
social and health system - and enabled the collection of data by others involved in patient care, such
as family members and caregivers, in cases in which
the patient was unable to answer questions due to
severe cognitive impairment or other disorders.(6,9)
Data were analyzed using the Statistical Package
for the Social Sciences (SPSS) for Windows version
17. A descriptive analysis was performed.
The development of the study met the national
and international standards of ethics in research involving human beings.
Gutierrez BA, Silva HS, Shimizu HE
Results
continuation
Variable
The sociodemographic profile of the 279 elderly
is presented in table 1. Most participants were
female, married, Caucasian, and claimed a religion. The average age was 72.3 years. The sample
was concentrated in the lower classes of education and income. More than half claimed to be
retired. Family income was one to three times the
minimum wage. As for the spiritual aspects, most
claimed to have a religion and considered having
it to be very important. In relation to family life,
31.2% lived with their spouses. The results revealed that most elderly considered their health
status compromised.
The INTERMED variables shown in table 2
indicate higher scores on the biological domain
variable “chronicity”, because 60.9% of participants had more than one chronic disease, and on
the variable “organization of care” in the health
care system domain, because 94.3% the elderly did
not have a perspective of discharge at the time of
interview. Also, in the health care system domain,
36.2% of the elderly were at risk for impediments
to health care.
Table 3 shows that the biological domain is the
most compromised and, also, that the total INTERMED score, a value that characterizes the complexity of patient care, ranged from 3 to 43. The
mean total INTERMED score was 18.13.
Table 1. Sociodemographic profile of hospitalized elderly
Variable
n(%)
Gender
Female
151(54.1)
Male
128(45.9)
Total
279(100)
Ethnicity (stated)
White
181(65)
Black
46(16.4)
Brown
49(17.5)
Asian
3(1.1)
Education
continues...
n(%)
0 years
59(21.1)
1 to 4 years
167(59.7)
5 to 8 years
18(6.5)
9 to 11 years
18(6.5)
12 to 15 years
17(6.2)
Marital status
Married
124(44.4)
Single
97(34.8)
Widow(er)
26(9.3)
Divorced
25(9.0)
Stable union
7(2.5)
Occupation
Retired
178(63.8)
Pensioner
34(12.2)
Worked
30(10.8)
Neither worked nor was retired
37(13.2)
Family income
< 1 Minimum wage
102(36.6)
1 - 3 Minimum wage
129(46.2)
3,5 - 5 Minimum wage
26(9.3)
> 5 Minimum wage
22(7.9)
Religion
Claimed a religion
No
25(9)
Yes
254(91)
Degree of importance
Very important
216(77.1)
Fairly important
39(14.2)
A little important
24(8.7)
Lived
Alone
52(18.6)
With spouse
87(31.2)
With children
50(17.9)
With grandchildren
3(1.1)
With spouse and others
45(16.1)
With children and grandchildren
34(12.2)
Others
8(2.9)
Self-health perception
Good
135(48.6)
Fair
104(37.4)
Bad
39(14)
Acta Paul Enferm. 2014; 27(5):427-33
429
Biopsychosocial aspects and the complexity of care of hospitalized elderly
Table 2. Score of the variables in the biological, psychological and health care system domains
Score
Variables
Biological domain
Score
n(%)
n(%)
n(%)
n(%)
0
1
2
3
History
Chronicity
21(7.5)
20(7.2)
68(24.4)
170(60.9)
Diagnostic dilemma
78(28)
131(47)
55(19.7)
15(5.3)
Current state
Severity of symptoms / Compromising
Diagnostic / Therapeutic challenge
5(1.8)
62(22.2)
162(58.1)
50(17.9)
42(15.1)
161(57.7)
68(24.4)
8(2.8)
16(5.7)
102(36.6)
113(40.5)
48(17.2)
0
1
2
3
Prognoses
Complications and life-threat
Psychological domain
History
Restrictions in coping
176(63.1)
69(24.7)
22(7.9)
12(4.3)
Psychiatric dysfunction
195(69.9)
54(19.4)
28(10)
2(0.7)
Current state
Resistance to treatment
236(84.6)
31(11.1)
12(4.3)
-(-)
159(57)
54(19.4)
60(21.5)
6(2.1)
143(51.2)
89(31.9)
42(15.1)
5(1.8)
0
1
2
3
Social vulnerability
130(46.6)
112(40.1)
12(4.3)
25(9)
Social dysfunction
185(66.3)
59(21.1)
15(5.4)
20(7.2)
Residential instability
157(56.3)
100(35.8)
38(13.6)
7(2.5)
Restrictions of network
164(58.8)
63(22.6)
16(5.7)
14(5)
Social vulnerability
146(52.4)
111(39.8)
16(5.7)
6(2.1)
Health care system domain
0
1
2
3
Psychiatric symptoms
Prognoses
Mental health threat
Social domain
History
Current state
Prognoses
History
Care access
184(65.9)
49(17.6)
13(4.7)
33(11.8)
Prior treatment experience
211(75.6)
42(15.1)
19(6.8)
7(2.5)
Current state
Organization of care
11(3.9)
4(1.4)
1(0.4)
263(94.3)
Coordination of care
257(92.1)
20(7.1)
1(0.4)
1(0.4)
178(63.8)
80(28.7)
12(4.3)
9(3.2)
Prognoses
Impediments of the health care system / Health insurance
Table 3. Scores of the INTERMED domains
Domain
Mean
Standard deviation
Minimum
Biological
8.17
2.49
3
Maximum
14
Psychological
2.51
3.01
0
12
Social
3.04
3.15
0
15
Health care system
4.33
1.84
0
11
Total
18.13
7.24
3
43
t Teste = 0
Discussion
One limitation of this study is the prevalence bias,
typical of cross-sectional studies. Another limitation
is the lack of deep understanding of the subjective
dimension of the factors related to the biological,
psychological, social and health system domains by
using a quantitative measurement instrument.
430
Acta Paul Enferm. 2014; 27(5):427-33
Nevertheless, although this study was cross-sectional, with a specific population of elderly patients
at a teaching hospital, the indicators evaluated
through INTERMED were similar to those of international studies, which confirmed the importance of the use of this instrument by the multidisciplinary team to identify the complexity of care,
the social and the health care system vulnerability
for the hospitalized elderly.(8-11)
The profile of the elderly investigated in this
study showed a mean age of 72.3 years, females
predominated, with a socioeconomic income in the
range of three times the minimum wage, a profile
that was similar to that observed in the literature.
(12-15)
The increase in longevity was a response to the
evolution of medical science, however, the quality
Gutierrez BA, Silva HS, Shimizu HE
of life of the elderly was one of the greatest challenges in developing countries, where poverty and social
inequality were highlighted.(16)
The impoverishment of the social support network, combined with a reduced economic profile
and the worst objective (degree of dependence) conditions and subjective (satisfaction with their own
health and living conditions) health conditions may
predispose the elderly to negative health outcomes
that will increase the costs in the care network, if
properly planned long-term care is not implemented in its complexity and scope.(17)
It was found in this study that most elderly
lived with their families (spouse, children, grandchildren), thereby their closest support consisted of
the family. However, the high proportion of elderly
who reported living alone in their homes drew attention, reaching 18.6% of the sample, higher than
the rate described in the literature.(18) Therefore,
there is need for restructuring of health services that
includes supervision of the elderly at home.(19)
It is unquestionable that the social engagement
of the elderly in the family, community and social
activity groups enables improvements in self-esteem
and motivation for life.(20,21)
In this study, most elderly had negative perceptions of their health status, higher than the results
of the Brazilian study.(22)
Several factors contributed to confirmation of such
perceptions, with diseases and physical and mental
losses being the main factors. The disabling signs and
symptoms were expressive of body image, lower agility
and strength, which contribute to the dissatisfaction
with the health state. Nevertheless, some practices can
improve this condition, especially the practice of physical activities and regular health care.(21)
As for the complexity of care, the mean total
score was 18.13. However, 34.8% of patients had
total INTERMED scores greater than 20 points,
indicating a need for integrated care. These findings
were similar to one international study.(23) It was
also found that 6.1% of these patients were classified as high complexity with a score higher than 30.
There was evidence of improved health outcomes
following targeted intervention for patients identified as complex through INTERMED.(12)
Thereby, it is recommended that the more complex patients are followed after hospital discharge
by a multidisciplinary team that will enable comprehensive care in order to improve the biopsychosocial aspects.(24)
Moreover, coordination of care can be facilitated with the use of INTERMED, because it has
been correlated with clinical outcomes of patients
and their satisfaction with the care.(13,14)
The elderly in the study pointed to problems in
the health system, highlighting the variable, “organization of care”. These data indicated that there
were difficulties in the organization of integrated
care for the elderly, due to their vulnerability related to conditions resulting from the natural aging
process that required multiple forms of care. Studies
showed that the elderly often had multiple diseases,
which could cause limitation and dependence.(4)
In this sense, it should be emphasized that health
professionals must be prepared to assist the elderly
in the organization of their care, with services that
must be varied to meet their multiple needs. It is
important to build networks of elderly care. Thus, it
is noteworthy that the nurse may facilitate access to
comprehensive care management programs.
Efforts have been made to improve health service usage and costs with new management models, and comprehensive health care for people with
complex health conditions.(12)
It was found in this study that the elderly lived
with a range of biological, psychological and social
changes that increased susceptibility to diseases and
could even cause disability. The biological domain
was the most affected, mainly due to the chronicity of the diseases. This fact was consistent with the
result expected for elderly patients admitted to the
hospital, who most often are fragile and have more
complex care outcome.(22)
The psychological domain was less compromised. However, one should be aware of the need
to assess for the presence of depressive symptoms
in the elderly, because a study performed with
the elderly at home showed that 23.9% had these
symptoms and that they were associated with sociodemographic, health, and social behaviors of
the elderly.(25)
Acta Paul Enferm. 2014; 27(5):427-33
431
Biopsychosocial aspects and the complexity of care of hospitalized elderly
The importance of resuming the humanist
conception is emphasized in order to focus on
the health-disease process in the elderly, in order
to incorporate the assumptions of comprehensive
care and to expand relationships between individuals and social structures involved in activities
that promote, maintain and recover health. There
must be a model that meets the care model, beyond the interests of the marketplace, which consists of the organization of actions to intervene in
the health-disease process, articulating physical,
technological and human resources in an attempt
to achieve the resolution of health problems in a
collective manner.(26-28)
It is necessary to rethink the responsibilities of
the institutions facing the actual demands of the society and of the professionals in various areas of care
for the elderly, families and communities, in order
to introduce changes in the care model and social
support equipment.
Conclusion
The results of this study demonstrated the importance of the INTERMED method because it enabled the multidisciplinary team to use it effectively
for identifying the complexity of care, the biopsychosocial and health system vulnerability of the
hospitalized elderly.
The knowledge of biopsychosocial factors, and
of the health system, of the hospitalized elderly patient is important because it provides parameters
that guide possible improvements in health practices, in programs, and in the implementation of
public policies.
Collaborations
Gutierrez BAO contributed to the study design,
analysis and interpretation of data, revising the intellectual content and approval of the version to be
published. Silva HS collaborated in the development and statistical analysis of data, relevant critical revision of the intellectual content, and final
approval of the version to be published. Shimizu
HE contributed to the relevant critical revision of
432
Acta Paul Enferm. 2014; 27(5):427-33
the intellectual content, and final approval of the
version to be published.
References
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Acta Paul Enferm. 2014; 27(5):427-33
433
Original Article
Expression of domestic violence
against older people
Expressão da violência intrafamiliar contra idosos
Luana Araújo dos Reis1
Nadirlene Pereira Gomes1
Luciana Araújo dos Reis2
Tânia Maria de Oliva Menezes1
Jordana Brock Carneiro1
Keywords
Geriatric nursing; Nursing care; Aged;
Health of the elderly; Domestic violence
Descritores
Enfermagem geriátrica; Cuidados de
enfermagem; Idoso; Saúde do idoso;
Violência doméstica
Submitted
March 13, 2014
Accepted
July 29, 2014
Corresponding author
Luana Araújo dos Reis
Doutor Augusto Viana Avenue,
unnumbered, Salvador, BA, Brazil.
Zip Code: 40110-060
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400072
434
Acta Paul Enferm. 2014; 27(5):434-9
Abstract
Objective: To reveal forms of domestic violence experienced by older people with impaired functional capacity.
Methods: This descriptive, exploratory study, using a qualitative approach guided by the oral history method,
analyzed forms of violence. The oral histories told by older adults were used to identify the relationship between
violence and dependence on someone else. The content analysis proposed by Bardin was used as a technique
of systematic and objective analysis to describe the contents of the messages to categorize the data.
Results: Oral histories reveal that older adults are aware of the fact that their dependence on other people
exposes them to situations of violence, expressed as negligence, psychological abuse and misappropriation
of assets.
Conclusion: The expression of domestic violence experienced by older adults with impaired functional capacity
was revealed, which indicates a relationship between depending on other people and suffering domestic
violence.
Resumo
Objetivo: Desvelar as formas de expressão da violência intrafamiliar vivenciada por idosos com
comprometimento da capacidade funcional.
Métodos: Estudo descritivo, de caráter exploratório e natureza qualitativa guiada pelo método da história
oral, analisou as formas de violência, identificando através da história oral dos idosos sua relação com a
dependência de outrem e da análise de conteúdo proposta por Bardin, como técnica de análise sistemática e
objetiva de descrição dos conteúdos das mensagens para categorização dos dados.
Resultados: A história oral desvela que os idosos se dão conta que a dependência ao outro os expõem a
situações de violência, expressas pela negligência, violência psicológica e apropriação indevida de bens.
Conclusão: A expressão da violência intrafamiliar vivenciada por idosos com comprometimento da capacidade
funcional foi desvelada sinalizando que há relação entre a dependência de outrem e a vivência de violência
intrafamiliar.
Escola de Enfermagem, Universidade Federal da Bahia, Salvador, BA, Brazil.
Universidade Estadual do Sudoeste da Bahia, Jequié, BA, Brazil.
Conflicts of Interest: there are no conflicts of interest to declare.
1
2
Reis LA, Gomes NP, Reis LA, Menezes TM, Carneiro JB
Introduction
Over the last decades, life expectancy has grown
in Brazil, and population aging has become one of
the main challenges of these modern times.(1) This
scenario becomes even worse when, together with
social inequalities, there is lack of information,
age discrimination and disrespect to older people.
Advanced age carries the stigma of functional and
social disabilities suffered by an individual, often
turning the older person into a burden to his/her
family, which leads to both family and social exclusion and domestic violence.(2)
Domestic violence is defined as each and every
act of violence or neglect which harms well-being,
physical and psychological integrity, or freedom
and the right of a family member’s full development. These acts can be perpetrated inside or outside the household, by any family member who is
in a relationship of power with the assaulted person,
including people who play the role of parents, even
without any familial bonds.(3)
Upon an international consensus involving all
countries which take part of the International Network For the Prevention of Elder Abuse, the World
Health Organization has defined seven types of violence: physical abuse (defined as the use of physical
force); emotional or psychological abuse (defined
as the infliction of verbal or nonverbal aggressive
acts); neglect (defined as the refusal or failure to fulfill any part of a person’s obligations or duties to
an elder); self-neglect (the behavior of an elderly
person that threatens his/her own health or safety);
abandonment (the desertion of an elderly person by
an individual who has assumed responsibility for
providing care for him/her); financial or material
exploitation (the illegal or improper use of an elder’s funds, property, or assets), and sexual abuse
(non-consensual sexual contact of any kind with an
elderly person).(4)
Taking into consideration the complexity of violence and its consequences for the health of older
people, several authors have highlighted the need
for actions to face this phenomenon immediately.(5)
In this sense, learning the risk factors for domestic violence allows to identify older people who
experience this offense early and/or prevent these
situations from happening to them in the household setting. A study which investigated the protection network for older people in the city of Rio
de Janeiro, through the analysis of 763 complaints
registered at the police station for older people and
135 complaints registered at a special care center
for older people, emphasized the importance of implementing health surveillance measures, focused
on the prevention of diseases and offenses and on
health promotion, especially based on the maintenance of a peaceful family life between the older
people and their relatives.(6)
In the light of the foregoing, the objective of
this study was to reveal forms of domestic violence
experienced by older people with impaired functional capacity.
Methods
The study design consists of descriptive, exploratory research, using a qualitative approach guided by
the oral history method, which emphasizes the use
of oral narratives turned into written records, orienting social processes by favoring investigations
in the scope of cultural and individual memories.
Oral histories allow for the establishment of dialogical relationships, but they are not conversations,
they are scheduled meetings aiming especially at
recording information.
This study was developed in March and April of
2012, in a city located in the southwestern region of
the state of Bahia, Brazil.
Fifteen older people who are registered at
a Family Health Unit of the city were included. Eligibility of people who would take part of
the research was established with the following
inclusion criteria: people aged 60 years old or
older; living with relatives; presenting impaired
functional capacity and having cognitive conditions to answer the questions from the data collection instrument.
Data were collected in individual interviews
guided by a semi-structured script. The research
question was: How is your relationship with your
Acta Paul Enferm. 2014; 27(5):434-9
435
Expression of domestic violence against older people
relatives now that your functional capacity has been
compromised? All interviews were recorded on an
MP4 device and then entirely transcribed. The interviews took place on the house of the researched
older people, in a room that ensured their privacy
and confidentiality of information.
The data collected were organized based on
the categorical thematic content analysis technique proposed by Laurence Bardin, which includes three basic phases: pre-analysis, material
exploration, and inference and interpretation of
results, which allowed to outline the theme “Expression of violence experienced by older people” and the following categories: negligence,
psychological violence, financial exploitation
and physical violence.
The development of this study complied with
national and international ethical guidelines for the
research involving human subjects.
Results
Characteristics of the older people who
participated in the study
The older people interviewed were aged between 65
and 88 years, with prevalence of women (73.4%).
As for their marital status, 60.0% of the older people did not live with their partner, being widowed,
separated or divorced. Level of education varied
from being illiterate to having incomplete primary education. With respect to health issues, the
most commonly reported diseases were: systemic
arterial hypertension (80.0%), arthritis/arthrosis/
osteoporosis/rheumatoid arthritis (40.0%), diabetes mellitus (33.3%), low back pain (20.0%), and
cardiopathy (6.6%).
All of the people who participated in the research presented impaired functional capacity
for the development of instrumental activities
of daily living (IADL), and depended on a relative to perform activities such as: cleaning the
house, handling clothes, cooking, using household appliances, shopping, using personal or
public transportation, and controlling their own
medications and finances.
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Acta Paul Enferm. 2014; 27(5):434-9
Expression of the violence experienced
by older people
The interviewed older people with impaired functional capacity reported they experience domestic
violence, as presented in the following categories:
Negligence
The older people said they are neglected by their
relatives, who stopped providing for their basic care
needs for physical, emotional and social development, which is verified in their speeches:
[...] when they leave the older person locked
at home, with no food. There are moments I ask
God to take me right away and stop this suffering.
(I-3: Woman).
I don’t get out, nobody takes me to the church,
not even for a walk, I spend all day in this garage.
There are days I want to die. I cannot stand being
locked up like an animal (...) I don’t even know why
they allowed you to get in here, nobody enters here,
I never talk to anybody. (I-7: Woman).
My life was better before, I used to do things on
my own and people here did not order me around.
They used to respect me, to obey me. Now I am
abandoned in this room, I cannot even talk to people. (I-8: Man).
[...] it is sad when you want to do something
but you cannot [...] and it is even sadder to hear
other people complain when you ask for something.
(I-11: Woman).
They won’t take me to the doctor. I am a prisoner: I live in this house. The only thing I am entitled
to do is watching television. (I-13: Woman).
Psychological violence
As for psychological violence, the older people
mentioned they suffer rejection, disparaging and
disrespect, as shown in the speeches below:
There are moments they (children) say things
that are worse than an attack, you know? Words
that insult. You get hurt. It is impossible not to take
offense. (I-3: Woman)
The words she (daughter) says are more hurtful
than a punch. It is the worst! When someone hurts
you, you get better. Words offend. They keep on
our mind all the time. (I-9: Woman)
Reis LA, Gomes NP, Reis LA, Menezes TM, Carneiro JB
One day my grandson called me a bastard. Just
because I asked him to turn the computer off because I wanted to watch the news (I-12: Man)
[...] Now they throw insults at me, they tell me
to shut up, they tell I am a burden to them, they
complain even for giving me a glass of water [...] I
do not do this because I want to, if I was not bedridden, I would do things myself. (I-13: Woman).
Financial exploitation
Financial exploitation was also mentioned by the
older people who participated in the research. They
said they are afraid of experiencing this form of violence through the misappropriation of their assets.
I am afraid of getting worse, because he treats
me badly, he complains, he yells at me. The other
day, he wanted to sell my house. (I-3: Woman).
I am afraid of getting worse and that he might
put me in a home for older people to stay with my
house. (I-10: Woman).
The way things have been recently, I am afraid
my grandchildren might throw me out to stay with
my house. (I-12: Man).
I never thought I would work all my life to raise
my children, and when I got old they would steal
all my money and even insult me (…). (I-15: Man).
Discussion
The limitations of the results of this study refer to
the research design, as its empirical material and
oral histories told by the older people participating
in the research related to domestic violence experienced by older people with impaired functional
capacity can be biased by the subjects.
The results help nurses to reflect on their provision of home care to older people with impaired
functional capacity, with the aim of preventing
domestic violence, by pointing out the forms of
violence experienced by these people which must
be overcome.
The oral histories told by the interviewees reveal that they are aware of the fact that their dependence on someone else exposes them to situations of violence, expressed herein by negligence,
psychological violence and financial exploitation,
especially through misappropriation of assets.
These forms of elder abuse were also revealed in
a study based on scientific productions published
from 2001 to 2008, which also highlighted physical and sexual abuse.(6)
Another study showed that negligence was the
most common form of domestic violence against
older people. It revealed that, of the 424 documents
analyzed as for violence cases, approximately 40%
of them referred this kind of abuse.(7)
An exploratory study carried out between 2002
and 2005 analyzed the presence, frequency and
forms of elder abuse through complaints made by
telephone and identified that, in terms of negligence, the number of complaints is not expressive,
accounting for only 13% of the total complaints
made in the year of 2002. Of these, the vast majority referred to cases of negligence suffered at institutions dedicated to providing care to older people.(8)
These studies reveal that elder abuse not only is
perpetrated by family members, but also by health
service workers, including healthcare professionals.
Such professionals should pay close attention to
these forms of abuse to identify cases of negligence
against older people, especially in the older people’s
home, a space considered protective, but which has
been revealed as a setting of family abuse.
Another form of domestic violence against
older people highlighted in this study is related to
psychological abuse. A study carried out with older people who lived in areas assisted by the Health
Family Program in the city of Rio de Janeiro, Brazil,
revealed that, among the people interviewed, 43%
reported at least one episode of psychological abuse
in the last year.(5) Another study developed in Fortaleza, Ceará, Brazil, whose locus was the collection
of documents of a service that receives elder abuse
reports, revealed a percentage of 35.2% complaints
related to psychological abuse.(9)
Regarding financial exploitation, our findings
revealed that older people are afraid of experiencing
this form of violence through misappropriation of
their assets, especially their house. To express this
form of violence, a quantitative study conducted
with 13 older people revealed that they suffer finanActa Paul Enferm. 2014; 27(5):434-9
437
Expression of domestic violence against older people
cial exploitation. One of the interviewees said that
his relatives did not visit him much and, when they
did, they were interested in his pension.(10)
In these situations, besides the financial exploitation, it is also important to think of the
psychological aspect, because the older person
sometimes feels helpless in face of the situation,
which generates an avalanche of losses, financial, psychological and even physical, which are
sometimes irreversible.(11)
In this context, it is important to emphasize
that complaints of financial abuse are related to
other forms of elder abuse, such as psychological
and physical abuse, which may cause injuries and
even lead to death.(10) In agreement with these
findings, a study conducted in Camaragibe, Pernambuco, Brazil, revealed that, in a sample of
315 older people, 66 reported suffering elder
abuse. Psychological abuse was the most common form of violence (62.1%), followed by
physical abuse (31.8%).
Older people are subjected to physical and verbal violence not only in the family, but also in institutions, where they suffer abuse, abandonment,
discrimination and isolation. They suffer because
their rights, which are guaranteed by the Brazilian
Constitution, are poorly divulged and there are not
specialized and specific public services for older
people, with priority care.(12)
According to the Brazilian Statute for Older
People, aging is a personal right and its protection
is a social right, with the State and society being
responsible for protecting the life and health of
older people, watching over their dignity and protecting them from any cruel, frightening, violent,
shameful or embarrassing treatment. The person
who commits acts of negligence, discrimination,
violence, cruelty or oppression, either by act or
omission, to older people shall be punished according to the law.(13)
Therefore, elder abuse represents a serious
infringement of older people’s rights as citizens,
showing a backlash against social evolution regarding the affirmation of human rights. As for
domestic violence, this type of felony is the one
which most transgresses the principles covered by
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Acta Paul Enferm. 2014; 27(5):434-9
the rights that defend and protect older people,
however, it is perpetrated for a number of reasons,
such as: 1. Competent authorities do not apply effectively what is established in the Brazilian Statute for Older People and other laws which protect
elderly people; 2. The older people are afraid of
revealing the abuse they experience.
A study revealed that, among the feelings expressed by the older people, they feel fear of retaliation, especially in the family; a sense of guilt for
generating a conflict; shame of the situation; and
fear of being institutionalized. Living with the abusers can not only affect these people’s health, but also
poses a big obstacle for the victim to make a complaint.(14)
The 4th section of the Statute establishes that
“No elderly individual will be object of any kind
of negligence, discrimination, violence, cruelty or
oppression, and any attack to his/her rights will be
punished, by act or omission, according to the law”.
The same section states that it is everyone’s duty to
impede threats or th violation of the rights of the
elderly.(13) On this perspective, it is important to denounce evident acts and traces of violence. Society
cannot wait for the confirmation of an abuse to denounce it, as this constitutes a strategy to help the
elderly live with no violence.
In this sense, the responsibility of healthcare
professionals towards older people’s well-being is
established in the section 19 of the Statute, which
states it is mandatory to report suspected or confirmed cases of elder abuse to the police, to the Department of Public Prosecution to the Council for
the Elderly. Section 57 establishes that if the healthcare professional does not denounce an identified
act of violence, he/she will be fined, with this fine
being calculated by a judge, taking into consideration the damage suffered by the older person and,
if the felony occurs again, the value of the fine is
doubled.(13)
Healthcare professions must have an active
participation in the care of abuse victims, in an
articulated and interdisciplinary manner, with
other social sectors, in order to protect the older
person and punish the abusers. Healthcare services must monitor these occurrences and create
Reis LA, Gomes NP, Reis LA, Menezes TM, Carneiro JB
conditions to prevent this kind of abuse, leading
to the reduction of the high levels of mortality derived from this form of abuse and its consequences: fear, alienation, posttraumatic stress disorder
or even depression.(14)
Nurses, in their everyday practice, are exposed
to different forms of abuse. Therefore, a process of
constant awareness through continuing or permanent education is necessary. This approach should
be characterized as an opportunity for a dialogue
which allows for a necessary personal and professional reflection, as one cannot exclude the other.
In this awareness process, it is important to have
specific scientific information and to include spaces
of reflection about the difficulties that go beyond
education practice of each area of expertise, because
dealing with cases of abuse demands thoughts beyond disciplinary boundaries, in order to create better listening and intervention strategies.(15)
Conclusion
Impaired functional capacity and dependence on
other people are deemed risk factors for domestic
violence and, the difficulty to obtain oral reports
from older people who experienced domestic violence and make them commit to a preventive care
project are limiting.
Acknowledgements
The authors thank the Coordination for the Improvement of Higher Education Personnel (CAPES) for the
master scholarship granted to Luana Araújo dos Reis.
Collaborations
Reis LA and Gomes NP contributed to the project
conception, research development, and writing of
the article. Reis LA collaborated with the writing
of the article, relevant and critical review of its intellectual content, and final approval of the version
to be published. Menezes TMO and Carneiro JB
contributed to the relevant and critical review of the
intellectual content, and final approval of the version to be published.
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2008;11(4):389-97. Portuguese.
11. Sanches AP, Lebrão ML, Duarte YA. [Violence against aged people: a
new issue?] Saúde Soc. 2008;17(3):90-100. Portuguese.
12.Silva CC, Gomes LG, Freitas CM, França IS, Oliveira, RC. [Major na
tional and interna tional social policies in elderly laws]. Est Interdiscipl
Envelhec. 2013;18(2):257-74. Portuguese.
13. Brasil, Lei nº 10.471, de 1ª de outubro de 2003. Dispõe sobre o Estatuto
do Idoso e dá outras providências. In: Presidência da República. Portal
Legislação. Brasília, 2003. [citado 2013 Mai 10]. Disponível em: http://
www.planalto.gov.br/ccivil_03/leis/2003/L10.741.htm.
14.Oliveira AA, Trigueiro DR, Fernandes MG, Silva AO. [Elderly
maltreatment: integrative review of the literature]. Rev Bras Enferm.
2013; 66(1):128-33. Portuguese.
15. Wanderbroocke AC, Moré CL. [Meanings of family violence against the
elderly from the standpoint of professionals in Primary Healthcare].
Cien Saude Colet. 2012;17(8): 2095-103. Portuguese.
Acta Paul Enferm. 2014; 27(5):434-9
439
Original Article
Assessment of attributes for family and
community guidance in the child health
Avaliação dos atributos de orientação familiar
e comunitária na saúde da criança
Juliane Pagliari Araujo1
Cláudia Silveira Viera2
Beatriz Rosana Gonçalves de Oliveira Toso2
Neusa Collet3
Patrícia Oehlmeyer Nassar2
Keywords
Primary health care; Children’s health;
Family health; Health evaluation;
Pediatric nursing
Descritores
Atenção primária à saúde; Saúde da
criança; Saúde da família; Avaliação em
saúde; Enfermagem pediátrica
Submitted
March 24, 2014
Accepted
July 29, 2014
Corresponding author
Juliane Pagliari Araujo
João XXIII street, 600, Londrina, PR,
Brazil. Zip Code: 86060-370
[email protected]
Abstract
Objective: To identify the extension in primary health services of attributes for family and community guidance
about the health of children health.
Methods: This was a quantitative, cross-sectional and evaluation study. We administered 548 questionnaires
(Brazilian Primary Care Assessment Tool, child version) to families and/or legal guardians of children younger
than 12 years of age who were received care in 24 health units. Data were analyzed using SPSS software,
version 17.0.
Results: The basic public health services of the studied municipality were below what is considered ideal for
primary health care with regard to the attributes of family and community guidance. Score of these attributes
were 4.4 and 5.1, respectively. Scores considered satisfactory were ≥6.6.
Conclusion: We found that it was difficult for services to integrate families and the community in the care
process. This finding reinforces the healing care culture and individual-centered care.
Resumo
Objetivo: Identificar a extensão dos atributos da orientação familiar e orientação comunitária na atenção à
saúde da criança nos serviços de atenção primária.
Métodos: Estudo quantitativo, transversal, do tipo avaliativo. Foram aplicados 548 questionários PCATool
- Instrumento de Avaliação da Atenção Primária - Brasil versão criança aos familiares e/ou cuidadores de
crianças menores de 12 anos atendidas em 24 unidades de saúde, sendo os dados analisados no programa
SPSS 17.0.
Resultados: Os serviços básicos de saúde pública do município estudado possuem um percentual abaixo
do considerado ideal para a atenção primária à saúde nos atributos de orientação familiar e orientação
comunitária. O escore desses atributos foram 4,4 e 5,1, respectivamente, sendo considerados satisfatórios
valores de escore ≥ 6,6.
Conclusão: Identificou-se a dificuldade dos serviços em integrarem a família e a comunidade no processo de
cuidado, fortalecendo a cultura de assistência curativa e centrada no indivíduo.
Instituto Federal do Paraná, Londrina, PR, Brazil.
Universidade Estadual do Oeste do Paraná, Cascavel, PR, Brazil.
3
Universidade Federal da Paraíba, João Pessoa, PB, Brazil.
Conflicts of interest: none reported.
1
DOI
http://dx.doi.org/10.1590/19820194201400073
440
Acta Paul Enferm. 2014; 27(5):440-6
2
Araujo JP, Viera CS, Toso BR, Collet N, Nassar PO
Introduction
Building and reorganization of public health policies in Brazil and around the world make up a
long process that requires reflection to determine
gaps in current care models. To reorganize the
health system and strengthen clinical practice, investments in and changes to Primary Health Care
(PHC) are needed.
In Brazil, the main proposal for PHC organization centers on the family health strategy
(FHS). including basic care services characterized
by continuity and integrality of care in a population from a specific area.(1) However, in the current Brazilian health system FHS coexists with
the traditional basic health units (BHU), the
characteristic of which is assistance with spontaneous demand.
In the context of PHC, child health care presents some weaknesses. A recent literature review(2)
reported that PHC for children does not effectively
distinguish between this point of attention and the
other parts of the current health system. This lack of
articulation shows the lack of effective coordination
in PHC; it also implies that not all possibilities for
pediatric health care are being addressed, thereby
leading to unresolved care.(3)
To establish that the health units (BHU and
FHS) are the main entry points to the health system and to obtain better results for PHC services,
the principles of these units must be operationalized; therefore, structured PHC in agreement with
its essential attributes (family and community
guidance and cultural competence) would be more
efficient and can improve resolution of care. Our
study focused on attributes of family and community guidance.(4)
Family guidance considers the family as the
object of care. The center of care is directed toward the knowledge of the multidisciplinary
team and family members about the family health
problems. (4,5)
Community guidance presupposes the knowledge of characteristics of community health and of
local resources designated for cultural, leisure and
other activities. Such knowledge provides a broader
way to assess health needs than an approach based
only on interactions with patients or their families.(4)
For pediatric health care, attributes of family
and community guidance must be present because
they strengthen the bond with health services and
reflect the extension of further attributes, making
health care for children more effective.
Assessment of health services in Brazil has
become an increasing focus of scientific and institutional movements, indicating the need to
include such assessment in planning and implementation of health programs. For this reason, a
number of studies have been conducted to verify
extension of essential attributes of an efficacious
PHS. (6-8)
When considering the PHS as an attempt to
reorganize health system, it is necessary to reflect,
among other aspects, on characteristics of care delivery and the focus of attention. In this way, the
development and broadening of studies on health
services are needed, particularly because the reduction in child morbidity and mortality is directly related to the quality of care delivered. The objective
of the current study was to identify to what extent
family and community are involved in the pediatric
care process in PHS.
Methods
This was a cross-sectional, descriptive and evaluation study with a quantitative approach of
health care services models of FHS and traditional BHU in pediatric health care in Paraná
in southern Paraná. This study is part of multicenter project involving the Universidade Estadual de Londrina and Universidade Federal da
Paraíba. As part of this project, therefore, this
research was developed in 24 health units (23
BHUs; 1 unit with 2 family health teams) in urban area of the municipality.
We estimated the sample size by probabilistic
stratified sample causation with proportionated
share by unit. The sample consisted of 548 caregivers of children younger than 12 years of age
who were receiving care in the mentioned units.
Acta Paul Enferm. 2014; 27(5):440-6
441
Assessment of attributes for family and community guidance in the child health
Of this total, 17 were from an FHU and 531 from
a BHU. To administer questionnaires, caregivers
were selected by systematic sampling while they
were waiting in line for nursing and medical consultations in the units. The following inclusion
criteria were used: participants needed to be users
of the service and have attended at least two consultations in the unit within the six months before
data collection.
Data were collected from October 2012 to
February 2013 using the Brazilian PCATool (Primary Care Assessment Tool), child version.(9) The
questions concern all essential attributes and derivations; the attributes of family guidance are elicited in three questions that concern the family’s
opinion about the child’s treatment, the history of
family diseases and the encounter of the professional with the family. With regard to the attribute for community guidance, four questions addressed the use of home visits by the health team,
the knowledge of professionals, community health
problems, and participation of families in local
health councils.(9)
Responses on the instrument were given by
Likert scale with the following options: definitely
yes (4); probably yes (3); probably not (2); definitely not (1). To obtain the score of each attribute, the
mean of each element was calculated, thereby constituting a mean attribute. The mean of each attribute was transformed on a scale of 0-10 as follows:
(score obtained-1) × 10/3.(9) For this transformed
score, a cutoff point ≥ 6.6 is considered satisfactory
for the extension of attribute in PHC. It is important to emphasize that this score is equivalent to a
value of 3 or greater on the Likert scale because values < 6.6 were considered low.(10,11)
Questionnaire response were digitized into a
database created in Excel 2010 with double entry.
Data were transferred to SPSS software, version
17.0, for analysis. Data are reported as mean, standard errors, minimum and maximum for each item
of derivate attributes. Results described are presented with absolute and relative distribution.
Development of this study followed all national and international ethical and legal aspects of research on human subjects.
Results
Of 548 applied questionnaires, 440 (80.29%) indicated that the main caregiver of the child was the
mother; 272 parents (49.6%) were married. Of
children participating in the study, 228 (41.61%)
were an only child. A total of 434 (60.94%) families
had income equal to as high as two times the minimum wages. With regard to water and wastewater,
526 (95.99%) and 310 (56.57%) of respondents
had treatment by official network, respectively.
The regular source of care for PHC services was
the nurse for 6.4% of respondents and physician for
41.1%; both types of professionals were employed
in the health service (Table 1).
Table 1. Professional or health service mentioned by the
caregiver in relation to affiliation degree
Professional / service
n(%)
Nurse
35(6.4)
Physician
225(41.1)
PHC Service
288(52.5)
Total
548(100.0)
n – 548; PHC - Primary Health Care
Table 2 presents results related to each element
that makes up the attribute of family guidance in
PHC services.
Table 2. Attribute of family guidance
PHC Services
Variables
X
SE
Minimum
The health professional asked your opinion on the child’s treatment and care
2.2
0.677
1
4
The health professional asked about the family history of diseases
2.4
0.720
1
4
Maximum
The health professional organized a meeting with child’s relatives
2.3
0.563
1
4
Total
2.3
0.471
1
4
Mean score
4.4*
3.168
0
10
SE – standard error; * Transformed mean (0-10); PHC - Primary Health Care
442
Indicator(n=548)
Acta Paul Enferm. 2014; 27(5):440-6
Araujo JP, Viera CS, Toso BR, Collet N, Nassar PO
Table 3. Attribute of community guidance
PHC Services
Variables
Indicator (n=548)
X
SE
Minimum
Somebody in the service made home visits
2.9
0.666
1
Maximum
4
The service is aware of local community health problems
2.5
0.623
1
4
Services conduct surveys within the community to identify problems
2.4
0.606
1
4
Service invite family members to participate in health councils
2.2
0.631
1
4
Total
2.5
0.487
1
4
Mean Score
5.1*
0.162
0
10
SE – standard error; * Transformed Mean (0-10); PHC - Primary Health Care
Table 3 emphasizes results of each component
of attribute community guidance.
The mean scores for family and community
guidance in the health services investigated were 4.4
and 5.1, respectively. These values are below what is
considered satisfactory (6.6).
Discussion
This assessment of health services used a validated instrument that enabled us to identify to
what extent the attributes of family and community guidance are present in pediatric health care
in PHC services according to the perspective
of caregivers. It is important to emphasize that
these results presented must be interpreted with
caution because they reflect only the users’ vision. It will also be necessary to know the opinions of the PHC professionals.
Health service geared toward PHC that include family and community guidance favor
actions in plan and act, enabling nursing and
other health professionals to provide care that is
more effective and improves pediatric health indicators. However, in this study, caregivers mentioned that they received care from physicians
(41.1%) more than nurses (6.4%). For this reason, this study emphasizes the need to broaden
nurses’ clinical practice in pediatric care in PHC
services and in a broader clinical context because
no isolated knowledge can resolve complex population health problems. A broader clinical aim
may help overcome the barriers with traditional
clinic care by modifying the work process from
individual-centered care in a collective environ-
ment(12) to a care focus that is heterogeneous,
medically centered, and pragmatic.
In this study, the predominant care model in
the urban area of the studied municipality is of
traditional health (91.6%). Until the data collection period, only two active PHS teams existed
in this area, both located in the same physical
structure. Transformation of the care model must
begin by implementation of new PHS teams in
such a way that reflects an understanding of local
needs and characteristics for development of actions and that is oriented by national rules, such
as consolidation of care networks focused on social health determinants.
Changes in the work process of health teams
still produce tension because these changes propose alterations in conventional clinical practice
and health management; more democratic relations between health professionals and relations
with assisted population must be respected.(13) Part
of the challenge that PHC proposes is unstrained
labor relations and incorporation of children and
their families as protagonists of the care process.
This dichotomy between daily practice and the
goals of PHC resulted in weakened presence and
extension of attributes of family guidance, which
contribute to the lack of resolution of pediatric
health care.
A broader view of the role of the child and his/
her family favors the construction of integrative
and resolution care. It also helps reinforce the characteristics that PHC espouses, including attempts
to reduce pediatric morbidity and mortality from
avoidable causes.
To address the needs for family guidance,
health services must present other characterActa Paul Enferm. 2014; 27(5):440-6
443
Assessment of attributes for family and community guidance in the child health
istics related to the PHC, such as longitudinal
aspects. For the service to be identified as the
regular source of medical attention, the family’
knowledge of the origin and diseases care is essential. To address this assumption, one of the
survey questions related to existing diseases in
the child’s family. In the evaluated health service,
the mean score for this element was less than
3.0 (Table 2), which demonstrate that the service did not integrate family care. This finding
also shows the weakness of other characteristics
of PHC, besides family guidance, such as longitudinal care and community guidance. In this
sense, family participation in the decisions concerning child care is critical so that the care focus
is not fragmented and that the needs of the child
and his/her family group are addressed.
Family integration in child health care, as well as
the integration of health service and its professionals in family care broaden the relationship among
the participants, remodeling the focus of health
care. Despite that, in the studied municipality, individual-centered care was highlighted; care focused
mainly on family was not evident throughout the
follow-up of life cycle of children aged 0 to 12 years
(Table 2). The attribute of family guidance in the
PHC was not seen as part of the daily routine for
delivering care to the child.
A mean score of 4.4 was identified in the assessment of the attribute of family guidance. This
attribute also had unsatisfactory value in any of
the services evaluated by users of BHU and FHS
in previous studies conducted in Minas Gerais
and São Paulo, as well as in Santander, Colombia.(7,14,15) However, research carried out in FHS
units(6) with children younger than 1 year of age in
the countryside of São Paulo reported a high score
for this attribute; this finding diverged from previous studies. This discrepancy can be explained
by the fact that participants in the latter study(6)
were from a single family health unit; the study
did not involve all units of the municipality or the
selected health district.
In the municipality of the current study, the
territorial process was concluded in 2012; however, according to data reported by interviewers, gaps
444
Acta Paul Enferm. 2014; 27(5):440-6
remained in diagnoses among the enrolled community, especially because services are not close enough
to the community. We emphasize that the mean was
unsatisfactory for all of the assessed elements (Table
3), which indicates the weakness in other attributes
of PHC, such longitudinal care, access, integration
of care, and family guidance.
One of the tools that PHC uses to understand the community is the home visit. This activity should be done by all health professionals.
However, in this study, the mean score for this
requisite was 2.9. Although home visits are an
important tool, this practice is not conducted
effectively and often is not integrated into the
services care plan. Our study highlights that
professional education in directions not compatible with those proposed by PHS and the
massive presence of biomedical technology favor
this negative aspect. Related to this aspect is the
organizational environment of health services,
which has a very complex dynamic involving
users, health professionals, and their self-governors and the service administration. For this reason, focus on changes in the working process in
health care led to several reflections concerning
macro and micro policies.
In this context, the FHS is a care model that
progresses slowly because it is based on broad objectives and involves community agents. In addition, little attention has focused on work conducted within these teams, particularly interdisciplinary practice in the daily routine of health care in
such services.(14) Continuing education in health
can be a strategy to generate new knowledge and
broaden discussions in working environment, integrating the health team to identify strong and
weak points of the service, reflecting the integral
care to the child.
To improve the performance of services with relation to community guidance, it is imperative to
understand the role of the service in community
health problems. The assessed services had a mean
score that was lower than ideal (Table 3), which
showed a weakness of services concerning integration with the community. An approach oriented to
the community links the clinic, epidemiology, and
Araujo JP, Viera CS, Toso BR, Collet N, Nassar PO
social sciences, so that programs can be changed
based on needs and the efficacy of such changes can
be evaluated.(16)
The survey in the community to identify its
problems also showed an unsatisfactory mean
score. Listening to the population is important because health professionals often act as if they know
the needs of the population and take for granted the way they should to act; they also assume
interventions involving only technical knowledge
are sufficient for effective care. Health problems or
needs of the population must be take into account
based on social health determinants.(17)
The scores of the other studies(7,8,14,15) on assessment of attribute of community were also considered unsatisfactory. It is evident that the score of
attributes of family and community guidance (4.4
and 5.1, respectively) did not address the PHC
goals of including the family and community in
pediatric care, strengthening the culture of individual-centered care. The need to broaden PHC
is clear in the municipality where this study was
conducted based on the working process centered
on such clinical widening, which emphasize the
focus on family and children in their cultural context and in the community needs. For this reason,
this broadened focus will entail the reformulation
of public policies in the municipality, as well as in
some aspects related to the structure and care process for an effective implementation of high-quality PHC services.
Conclusion
Attributes of family and community guidance had
lower score in child health care based on assessment
of users of primary care services. The service did not
reach its total extension, which compromised the
affiliation degree to the service and resolution of
child health care in the PHC.
Acknowledgments
To the National Council for Scientific andTechnological Development – CNPq (Notice # 014/2001); to
the research group in mother-child nursing –
GPEMI; to undergraduate students of nursing
and medicine programs and graduate students in
public heath graduate program at Universidade
Estadual do Oeste do Paraná - UNIOESTE, Campus Cascavel-PR.
Collaborations
Araujo JP; Viera CS and Toso BRGO contributed
with project design, data analyses and interpretation; Araujo JP; Viera CS; Toso BRGO; Collet
N and Nassar PO contributed to critical revision
of important intellectual content , drafting the
manuscript and final approval of the version to
be published.
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Original Article
Validity of instruments used in nursing
care for people with skin lesions
Validade de instrumentos sobre o cuidado de
enfermagem à pessoa com lesão cutânea
Roberta Kaliny de Souza Costa1
Gilson de Vasconcelos Torres2
Marina de Góes Salvetti2
Isabelle Campos de Azevedo1
Maria Antônia Teixeira da Costa1
Keywords
Nursing assessment; Nursing care;
Validation studies; Wound healing; Skin/
injuries
Descritores
Avaliação em enfermagem; Cuidados
de enfermagem; Estudos de validação;
Cicatrização; Pele/lesões
Submitted
June 25, 2014
Accepted
July 29, 2014
Abstract
Objective: To validate the content of two instruments used to evaluate nursing care for people with skin
lesions.
Methods: Content validation study comprised of two stages: the first was the development of the instruments,
beginning with a literature review; the second, content validation by means of an evaluation conducted by 30
judges/experts. For analysis, the Kappa coefficient ≥ 0.61 and content validity index ≥ 0.75 were adopted.
Results: The judges presented nine suggestions regarding the instrument’s categories. All items of the
questionnaire and the observation script reached acceptable rates of content validity and concordance. Some
categories attained scores above the given value, confirming the validity of the content.
Conclusion: The instruments showed satisfactory content validity rates, and can be used to measure the skills
and knowledge of nursing care provided to people with skin lesions.
Resumo
Objetivo: Verificar a validade do conteúdo de dois instrumentos para avaliar o cuidado de enfermagem à
pessoa com lesão cutânea.
Métodos: Pesquisa de validação de conteúdo que compreendeu duas etapas: a primeira foi a elaboração dos
instrumentos, a partir de uma revisão da literatura; a segunda, de validação de conteúdo, mediante a avaliação
dos instrumentos por 30 juízes/especialistas. Para análise, adotaram-se coeficiente Kappa ≥0,61 e índice de
validade de conteúdo ≥0,75.
Resultados: Na avaliação das categorias de composição dos instrumentos, verificaram-se nove sugestões
indicadas pelos juízes. Todos os itens do questionário e do roteiro de observação obtiveram índices aceitáveis
de validade de conteúdo e de concordância. Algumas categorias alcançaram escores acima do valor
determinado, confirmando a validade de conteúdo.
Conclusão: Os instrumentos apresentaram índice de validade de conteúdo satisfatório, e podem ser utilizados
para avaliar a habilidade e o conhecimento sobre o cuidado de enfermagem à pessoa com lesão cutânea.
Corresponding author
Roberta Kaliny de Souza Costa
André Sales street, 667, Caicó,
RN, Brazil. Zip Code: 59300-000
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400074
Universidade do Estado do Rio Grande do Norte, Caicó, RN, Brazil.
Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil.
Conflicts of interest: there are no conflicts of interest to declare.
1
2
Acta Paul Enferm. 2014; 27(5):447-57
447
Validity of instruments used in nursing care for people with skin lesions
Introduction
Wounds are among the most common skin problems in everyday health care services. With high
incidence and prevalence in the population, skin
lesions cause great harm to the lives of individuals
and their families, and cause economic impact on
health care services.(1)
The quality of care for people with wounds requires
comprehensive care provided by trained professionals,
and systematized by protocols that guide the practice
of preventive, diagnostic and treatment conduct.
As members of the health care team, nurses play
an important role in treating this clientele, diagnosing the problem, monitoring its evolution, and
applying dressings at home and at health services.
(2)
Performance evaluation should seek to grasp the
knowledge acquired by future professionals, in addition to identifying their ability to perform specific
tasks, using, integrating and applying their learned
theory to solving problems in real situations.
The instruments for this type of evaluation
should be grounded in scientific evidence, essential
to the quality, legitimacy and credibility sought in
its validation process.(3)
The validation of an instrument verified its
ability to measure a phenomenon, and may be performed using various methods. In turn, content
validation is one of the psychometric measures essential to the development of measurement tools,
which involves the process of preparation and trial
by experts, in defining the theoretical universe and
different dimensions of the concept to be observed
and measured.(4)
Thus, the use of reliable instruments is a valuable resource in the evaluation of nursing care, especially during professional training, since it facilitates the production of data, favors the analysis of
techniques and approaches adopted, and provides
standardization of efficient conduct in teaching and
clinical practice.
However, the lack of validated measurement
tools in literature to evaluate nursing care for
people with skin lesions reinforces the importance of constructing and validating tools for
this purpose.
448
Acta Paul Enferm. 2014; 27(5):447-57
Thus, this study aimed to validate the content
of two instruments that evaluate nursing care for
people with skin lesions.
Methods
Content validation was comprised of two stages:
the first was the development of the instruments,
beginning with a literature review; the second, content validation by means of evaluation of the instruments by 30 experts.
The judges were selected by performing an advanced search on Plataforma Lattes, which is a database containing researchers’ curricula vitae (CVs).
The search yielded 1,449 CVs, from which a purposive sample of 147 nurses was selected, based on the
following inclusion criteria: having a PhD or master’s degree in health sciences; working in undergraduate teaching; and having engaged in scientific
research and/or publication on wounds over the last
five years.
An invitation letter was sent by email to the
147 nurses, containing the objectives and methodology of the study, the rationale of the validation
process and request for participation in the study
as an evaluating judge. The letter also provided a
link to a form developed in Google docs (docs.
google.com), which the nurses should use for the
evaluations. Of the 147 professionals invited, 30
agreed to participate, thereby constituting the
study sample.
The data collection instrument sent to the
judges was comprised of three parts: identification
of professional characterization items; a structured, checklist-type observation script; and a
questionnaire with ten multiple-choice questions
to assess knowledge of nursing care for patients
with wounds.
In general terms, the content of the questionnaire considered the categories comprising the
checklist. The checklist included 20 items corresponding to the steps deemed important for nursing care of people with skin lesions.
The evaluation by the judges consisted of rating each item on the instrument as well as the in-
Costa RK, Torres GV, Salvetti MG, Azevedo IC, Costa MA
strument as a whole as “adequate” or “inadequate,”
according to the following criteria: usefulness/relevance, consistency, clarity, objectivity, simplicity,
feasibility, if it is up-to-date, vocabulary, accuracy
and sequence of instruction topics. Furthermore,
explanations of the inadequacies and suggestions
could also be made so that items could be modified
and improved.
After evaluation of the instruments, the Kappa
coefficient and Content Validity Index were applied
to verify the level of agreement of the judges in relation to the items evaluated. As criteria for acceptance, an agreement level of >0.61 (good level) for
the Kappa coefficient and ≥0.75 for the Content
Validity Index was established for the evaluation of
each item, as well as for the general evaluation of
each instrument.(5.6)
The data collected were organized into an electronic spreadsheet and exported to statistical software. After coding and tabulation, the data were
analyzed using descriptive statistics, with absolute
and relative frequencies, application of the Kappa
test and the Content Validity Index. The analysis supported the reformulation of instruments in
accordance with the guidelines and suggestions of
the judges.
The development of the study adhered to national and international standards of ethics in research involving humans.
Results
Thirty nurses participated as judges. The majority
(80%) was female, and their ages ranged between
25 and 59 years, with a mean age of 44.3 years.
As regards professional qualifications, the majority
had doctorate degrees (76.7%), experience in teaching and care (93.3%), and worked in the Southeast
(56.7%) of the country.
The length of experience in health care ranged
from one to 30 years, the mean being 12.8 years;
the period of work as a teacher ranged from one to
35 years, the mean being 15.3 years, with the predominant ranges from one to 10 years and 11-20
years of experience.
In evaluating the composition categories of the
instruments on nursing care for people with lesions,
nine suggestions given by the judges were verified,
of which five were adopted and four rejected by the
researcher after analysis and comparison with the
literature (Chart 1).
Chart 1. Suggestions of the judges, acceptance and rejection of suggestions, and justification by the researcher
Category of instrument
Suggestions of judges (n)
Acceptance
Justification
Uses accessible language when
addressing the person with lesion (1)
Yes
Verbal communication in a language that is familiar to the patient is important so that he or
she can understand the information provided to them, enabling the fulfillment of the delegated
actions to ensure successful treatment(7)
Combines the items “Identify risk factors”
and “Perform patient history”(1)
No
In the constitution of care guidelines for people with skin lesions, the identification of risk factors
appears as a separate item of the patient history(8)
No
Authors refer to the performance of a complete and detailed physical examination of the person
with skin lesion(8.9)
When evaluating the lesion, specifies the
volume, depth and width measurements(3)
Yes
The measurements will be specified and standardized to facilitate the implementation of the
instrument
Does not describe the saline jet stream
technique to clean the lesion(1)
No
When applying the dressing, divides the
item into clean and sterile techniques(3)
No
Follow-up and guidance to people with
skin lesions and their relative/caregiver
Includes nutrition guidance in health
education actions for people with skin
lesions(1)
Yes
Records and documentation
Makes a record of the use of popular
practices(1)
Yes
Final observations
In the item relating to organization of the
environment, provides details regarding
the procedures used to organize the
environment(5)
Yes
Initial observations
Assessment of the person and skin
lesion
Includes directed physical exam(5)
Care of the wound and surrounding
skin
Technique described in literature(10,11)
We opted for the sterile technique, since the instrument will be collected in hospitals and health
care units. In the environment of health care services, sterile technique should be used(10)
The guidelines should include the benefits of eating certain foods that are important to health(12)
There are several popular therapies that are used in wound care(12)
The details of the procedures involved in organization of the environment, after treatment of a
person with skin lesion, standardizes and facilitates application of the instrument
The number of judges that suggested changes in the categories that compose the instruments is indicated by “n”
Acta Paul Enferm. 2014; 27(5):447-57
449
Validity of instruments used in nursing care for people with skin lesions
Table 1. Analysis of concordance of the judges on the categories of the checklist
Concordance analysis
Categories comprising the checklist
Kappa
CVI
Initial Care
0.76
0.87
Sanitizes hands
0.73
0.84
Medical history taking
0.78
0.87
Identifies risk factors
0.74
0.85
Performs physical examination
0.73
0.84
Checks vital signs
0.78
0.88
Assesses the presence of pain
0.77
0.87
Evaluates the skin lesion
0.72
0.83
Identifies signs of infection
0.76
0.85
Identifies the need for, and provides exams
0.82
0.90
Cleans wound
0.65
0.78
Applies dressing
0.66
0.78
Assesses the need for debridement
0.79
0.87
Recommends coverage
0.81
0.89
Develops educational activities
0.85
0.91
Identifies and provides referral
0.84
0.91
Records clinical evaluation
0.81
0.89
Records lesion evaluation
0.82
0.89
Organizes the environment
0.74
0.85
Sanitizes hands after care
0.80
0.88
Initial observations
Assessment of the person and skin lesion
Care of lesion and surrounding skin
Referral and guidance to the person with skin lesion, relative/caregiver
Record and documentation
Final observations
CVI - Content Validity Index
In the result of the judgment of the observation checklist on nursing care for patients with
skin lesions, all items showed concordance within the prescribed level (Content Validity Index
>0.75 and Kappa coefficient >0.61). However,
some categories achieved excellent Kappa coefficients (>0.80) among the study judges, such as:
Identifies the need and provides additional tests;
Recommends coverage; Develops educational
activities; Identifies the need for and provides
referral; Records the clinical evaluation; and Records the evaluation of the lesion. Most items
presented a Content Validity Index well above
the given value, except for the following categories: Cleans the wound and Applies dressing
(Content Validity Index of 0.78). Both items
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Acta Paul Enferm. 2014; 27(5):447-57
also had the lowest Kappa value of the instrument (0.65 and 0.66, respectively) (Table 1).
In the analysis of concordance of the judges
on the questions of the questionnaire on knowledge of nursing care for people with lesion, it is
observed that all of the questions had Kappa and
Content Validity Index values within the minimum level adopted. Questions Q2, Q3, Q6, Q7,
Q9 and Q10 attained excellent Kappa values
(>0.80). The lowest levels of concordance among
the judges were on questions Q1, Q4, Q5 and
Q8. The Content Validity Index was much higher (≥0.90) than the given value on questions Q6,
Q7, Q9 and Q10 (Table 2).
The final version of the instruments is in the
appendix.
Costa RK, Torres GV, Salvetti MG, Azevedo IC, Costa MA
Table 2. Judges’ analysis of concordance regarding the knowledge questionnaire categories
Agreement analysis
Categories comprising the checklist
Kappa
CVI
Q1. What actions should be taken in the evaluation stage of a person with skin lesion?
0.76
0.86
Q2. Which aspects should be considered when evaluating the characteristics of the skin lesion?
0.81
0.89
Q3. Which signs of infection should be considered when evaluating the characteristics of the skin lesion?
0.82
0.89
Q4. Which aspects should be considered when choosing the dressing to be applied onto the skin lesion?
0.71
0.81
Q5. During the care of the wound and surrounding skin, what is the adequate procedure to perform during application of the dressing?
0.78
0.87
Q6. In the initial and subsequent evaluation of the skin lesion, the nurse should be aware of the wound characteristics that indicate the need to perform
debridement. What are these characteristics?
0.83
0.90
Q7. When recommending the coverage to be used in the treatment of the lesion, what should the nurse consider?
0.86
0.92
Q8. What debriding action products are used in the topical treatment of skin lesions?
0.76
0.86
Q9. What guidelines should be provided to the person with skin lesions and their relative/caregiver for continuing care?
0.82
0.90
Q10. When completing the record and documentation of the care process for a person with lesion, what should be done?
0.86
0.92
Q - Question; CVI - Content Validity Index.
Discussion
The results of this study show the type of validation
used as being a limitation, considering the opinions
of the judges and their concordance on the content
of instruments to assess nursing care for the person
with wounds.
This type of evaluation must be grounded on
the best sources of scientific evidence. Instruments
evaluated by experts are an important tool, with the
potential to contribute to nurses’ practice in teaching and care of this population.
Care of a person with skin lesions includes a
range of preventive, diagnostic and therapeutic
measures, requiring intervention by a trained health
professional to care for the patient comprehensively,
considering their individuality and specifics of the
wound. Reinforcing this idea, an increasing number
of studies have shown the need for the health care
system to care for people with lesions, with guidelines and protocols that support decision-making
and guide professional practice.(2,13)
The active and organized work process of nursing care for people with lesions should be practiced
in services, and taught in undergraduate courses,
contributing to the quality of care and preparation
of the professional to act in this context.(14)
Corroborating the opinions of the judges participating in the research, one study(13) that char-
acterizes care protocols for people with wounds in
Brazil showed that activities involved in evaluating
the person and the wound, care of the wound and
the surrounding skin, documentation and recording of clinical findings, and referral and education
of the person, family member and/or caregiver are
all important elements in the comprehensiveness of
recommendations and guidelines for care of people
with skin lesions.
With regard to procedures prior to evaluation
of the people and their wounds, there was good
concordance among the judges on items focused on
receiving the person with lesions, preservation of
privacy, hand hygiene and explanation and request
for permission to perform procedures.
Evaluation of a person and their wound corresponds to an initial and important stage of care,
crucial to the preparation and implementation
of treatment aimed at restoring skin health and
recovery of the person with lesion. This requires
knowledge, communication skills, observation of
health needs and care, and performance of propaedeutic techniques.
Among the procedures considered in this stage
of care that achieved concordance among the judges, the following are highlighted: a thorough medical history taking and detailed physical examination; the existence of risk factors; checking vital
signs and for presence of pain associated with the
lesion; and signs of infection and laboratory inActa Paul Enferm. 2014; 27(5):447-57
451
Validity of instruments used in nursing care for people with skin lesions
vestigation. These actions are considered crucial in
identifying the health condition of the patient and
diagnosing the wound, because they encourage detection of associated diseases and problems related
to the healing process.(13)
Once the survey of a patient’s condition and
wound characteristics is complete, the development of the diagnosis of care needs proceeds, related to the physical and psychological dimensions of
the person with a wound, essential to planning the
actions to be implemented in treatment. In this
stage of care, consonance between the judges and
the literature was verified regarding the application of procedures involved in the skin restoration
process, such as cleaning the lesion, need for debridement of the wound, application of dressings
and recommendation for topical therapy to be
used in treatment.(15)
In this study, the items related to cleaning the
lesion and the dressing had the lowest concordance rates among the judges. In these items, the
description of the parameter to be evaluated was
questioned regarding the use of irrigation of the
lesion with 0.9% saline solution jets. Suggestions
for improvement were also identified in order to
define the use of a clean or sterile technique, considering closure intention (primary, secondary and
tertiary healing).
The criticisms made by the judges highlighted
the need for production of best scientific evidence
regarding procedures and techniques involved in
care of people with skin lesions, as scarcity and
low level of evidence in publications regarding this
subject is observed. This contributes to the persistence of doubts and an incongruous variety of
procedures for evaluation and treatment of the
problem.
In aspects regarding the set of therapeutic
measures, there was high concordance among the
judges regarding strategies for referral and guidance of people with skin lesions, family member
and/or caregiver. Care of patients with wounds
requires multidisciplinary health intervention
and ongoing educational work, involving the
health care team, patients, family members and
caregivers.(13)
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Acta Paul Enferm. 2014; 27(5):447-57
Furthermore, it is noteworthy that all monitoring of a person with lesion, including successive evaluations, effectiveness of conduct, guidance,
training, products and therapeutic techniques used
at various stages of care, should be documented and
recorded, encouraging communication between the
multidisciplinary team, and providing diagnostic
and therapeutic benefits.(13,16)
Nurses represent the largest number of workers in health care institutions, directly aimed at
caring for patients with skin wounds. It is therefore crucial that nurses are trained to perform appropriate care.
In this sense, the use of instruments for evaluating the care provided to people with lesions
are capable of assisting in the guidance of care
practice and teaching, and is a strategy for organizing the work of diagnosis, treatment and
prevention of people with lesion, with a view
towards a holistic approach that considers the
individual as a whole, beyond the healing of her
or his lesion.
Conclusion
The instruments showed a satisfactory content validity index, and can be used to measure the ability
and knowledge of nursing care provided to people
with skin lesions.
Acknowledgments
To the Coordination of Improvement of Higher
Education Personnel and the State University of
Rio Grande do Norte (CAPES; UERN; doctoral
scholarship for Roberta Kaliny de Souza Costa and
CAPES/PNPD postdoctoral scholarship for Marina de Góes Salvetti).
Collaborations
Costa RKS; Azevedo IC and Torres GV contributed
to the design, analysis and interpretation of data,
drafting the article and critical review of the manuscript. GV Torres; Salvetti MG and Costa MAT
contributed to critical review of the manuscript and
approved the final content.
Costa RK, Torres GV, Salvetti MG, Azevedo IC, Costa MA
References
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routines for individuals with a chronic wound and their mental health].
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Appendix - Checklist Procedure
Facility of practice observation: (
) Health care unit (
Monitoring by the preceptor: (
) No (
) Yes
Verification categories (0) Inadequate (1) Adequate
) Hospital ( ) Other
Procedures
If 0 justifies
1
Initial observations
1.1
Introduction to the person with skin lesion ( )
Performs care indoors, ensuring the patient’s privacy and making him/her comfortable ( )
Explains the procedures to be performed ( ), (interview, physical examination, evaluation of the lesion, application of dressing, information).
Uses appropriate language ( )
Requests permission and collaboration, if the patient can collaborate ( )
1.2
Sanitizes hands before care ( )
Removes jewelry ( )
Performs simple hand hygiene with soap and water ( )
Opens the tap and wets hands, avoiding leaning against the sink ( )
Applies in the palm of hand liquid soap sufficient to cover all surfaces of the hands ( )
Soaps palms of hands by rubbing them against each other ( )
Scrubs palm of right hand against the back of the left hand, interlacing fingers and vice versa ( )
Interlaces fingers and scrubs spaces between fingers ( )
Scrubs the back of the fingers of one hand with the palm of the opposite hand, securing fingers with movement of backwards and forwards, and vice versa (
Scrubs right thumb with the help of the palm of the left hand, using a circular movement and vice-versa ( )
Rubs the fingertips and nails of left hand against the palm of right hand, closed in a clamshell, making circular motion and vice versa ( )
Scrubs right thumb with the help of the palm of the left hand, using a circular movement and vice-versa ( )
Rinses hands, removing soap residue. Avoids direct contact of soapy hands with the tap ( )
Dries hands with disposable paper towel, beginning with the hands and then the wrists ( )
2
)
Evaluation of the patient and lesion
2.1
2.2
2.3
Takes medical history (in the first evaluation), collecting information about:
Identification (name, age, sex, address, nationality, marital status, skin color, income, education level, occupation ( )
Emotional state ( )
Clinical-history/history of disease (hypertension, diabetes, heart disease, venous/arterial insufficiency, allergies) ( )
Drugs in use ( )
Personal habits (smoking, alcohol consumption, physical activity, hours of sleep, leisure) ( )
Family history ( )
Personal hygiene ( )
Nutritional state ( )
Mobility (walking, walking with assistance, bedridden) ( )
Bladder and bowel elimination ( )
Complaint and duration of symptoms ( )
History of current lesion and treatments performed ( )
Characterization of previous lesions ( )
Popular practice in the treatment of lesions ( )
Identification of patient’s caregiver and health care institution ( )
Uses printed materials that guide medical history taking ( )
Attention to risk factors:
Systemic (age, nutritional status, mobility, emotional state, general hygiene, incontinence, daily and work activity with risk of lesions, vascular insufficiency) (
Local (edema, skin dehydration, pressure, infection, necrosis, humidity, trauma) ( )
Invasive procedures ( )
Use of drugs ( )
Diseases associated ( )
Scales used in the identification of risk factors ( )
)
Performs physical examination of the person with skin lesion, from the head to the legs, making use of the techniques of inspection, palpation, percussion and auscultation (in the first assessment).
Physical examination directed in subsequent reviews.
The examination should include:
Identification of the characteristics of the skin, moisture, elasticity and turgor (attention to: mycoses, varicose veins, edema, lymphedema, pigmentation, hyperkeratosis, dermatitis, cyanosis,
temperature, dryness, lack of hair, calluses, deformities, cracks, protruding bony prominences) ( )
Checks weight ( )
Checks height ( )
Calculation of body mass index ( )
Palpation of peripheral pulses ( )
Conducting sensitivity test ( )
Measurement of the circumference of the calf and ankle ( )
Calculation of Ankle Brachial Index ( )
2.4
Checks vital signs: pulse, respiratory rate, blood pressure and temperature (
2.5
Assess the presence of pain associated with the lesion at baseline and subsequent evaluations before, during and after the completion of dressings ( )
Collects detailed information on pain, seeking the location, pattern (type, duration, improvement, worsening, use of medication to control pain), the effect of pain on sleep and daily activities (
Use of scales to assess pain intensity ( )
2.6
)
)
Evaluates the wound, identifying (during baseline and subsequent evaluations):
Type of lesion (surgical incision, laceration, bruise, burn, pressure ulcers, neuropathic ulcers, arterial ulcers, venous ulcers) ( )
Location of lesion ( )
Measurement of length (small - up to 20 cm2; medium - from 20 to 60 cm2; large - above 60 cm2) ( )
Measurement of depth (surface - to the dermis, partially deep - down to the subcutaneous tissue, deep - muscle and adjacent structures) ( )
Duration of lesion (acute - traumatic lesions that respond to treatment and heal without complication, chronic - of long duration and frequent recurrence) ( )
Characteristics of the wound bed (granulation tissue, epithelialization, slough, necrotic) ( )
Skin surrounding the lesion (normal, red, swollen, macerated, cyanotic, peeling, bullous, hematoma) ( )
Edges of the lesion (detached, attached, washouts, macerated, whitish, hyperemia, epithelial) ( )
Exudate (absent, serous, bloody, purulent, mixed patterns) ( )
Volume of exudate (little - up to 3 gauze, medium - 4 to 10 gauze, a lot - over 10 gauze) ( )
Odor (absent, grade I - felt when the dressing is opened; grade II without opening the dressing, grade III - foul and nauseating) ( )
Exhibition of anatomical structures (muscle, tendon, blood vessels, bone, organs) ( )
Evaluates the stage of tissue lesion in pressure ulcer (I. redness of intact skin; II. Bubbles/Lesions of small thickness (epidermis/dermis); III. Local skin lesion covering the subcutaneous site; IV. Total
lesion of the skin involving muscles, tendons and/or bones) ( )
Uses instrument/printed form to guide the assessment of the lesion ( )
continues...
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Costa RK, Torres GV, Salvetti MG, Azevedo IC, Costa MA
continuation
2.7
Assesses the presence of infection in the skin lesion, identifying signs of (in the initial and subsequent evaluations):
Increased pain ( )
Erythema surrounding lesion ( )
Edema ( )
Heat ( )
Purulent exudates ( )
Increased level of exudate ( )
Odor ( )
Systemic manifestations (hyperthermia, increased regional nodes, involution in wound healing) ( )
2.8
Identifies the need for and provides laboratory exams, considering the clinical picture of the person with skin lesion (
Requests laboratory tests in clinical protocol ( )
3
Care of the wound and surrounding skin
3.1
Cleans wound:
- Lesion healing by first intention:
Cleans the incision using two sides of gauze soaked with 0.9% saline solution, in unidirectional movements ( )
Cleans the edges of the lesion, using two sides of gauze soaked with 0.9% saline solution, in unidirectional movements ( )
Dries excess saline solution on the incision and edges, using two sides of gauze, in unidirectional movements ( )
Proceeds with mechanical cleaning of all surrounding skin with gauze moistened in 0.9% saline, in unidirectional movements. If dirt is present, cleans with antiseptics ( )
- Lesion healing by second and third intention:
Proceeds with mechanical cleaning of all surrounding skin with gauze moistened in 0.9% saline and unidirectional movements. If dirt is present, cleans with antiseptics ( )
Irrigates the edges of the lesion with jets of up to 0.9% saline solution (through a hole in the bottle with a 25x 8mm 40x12mm gauge needle), warm (when possible) or at room temperature, or cold for
bleeding lesions ( )
Irrigates the bed of the lesion with jets of up to 0.9% saline solution (through a hole in the bottle with a 25x 8mm 40x12mm gauge needle), warm (when possible) or at room temperature, or cold for
bleeding lesions ( )
3.2
Applies dressing with aseptic or sterile technique ( )
Lesion healing by first intention:
Sanitizes hands before applying dressing ( )
Collects all the material needed for the application of the dressing - 0.9% saline solution, procedure gloves, sterile gloves, sterile gauze, hypoallergenic tape or similar, plastic bag for disposal of the
material used ( )
Puts the patient with lesion in a comfortable position, maintains their privacy and explains what will be done ( )
Uses personal protective equipment ( )
Opens the dressing material without contaminating it ( )
Removes the previous dressing using the procedure gloves that are then discarded ( )
Carefully removes adhesive tapes with 0.9% saline solution, making sure that there was no adherence on the lesion, moistening with saline solution until it detaches, if this occurs ( )
Disposes of the dressing removed, along with gloves used, in a separate plastic bag for this purpose ( )
Proceeds with cleaning of the lesion ( )
Uses sterile gloves or tongs to handle the lesion ( ).
Occludes the lesion with sterile equipment (when there is exudation) ( )
Applies the dressing with hypoallergenic tape or similar ( )
Discards contaminated material in separate plastic bag for this purpose, organizing environment ( )
Sanitizes hands after applying dressing ( )
Lesion healing by second and third intention:
Sanitizes hands before applying dressing ( )
Collects all the material needed for application of the dressing, including 0.9% saline solution, procedure gloves, sterile gloves, sterile gauze, hypoallergenic tape or similar, crepe dressing, 40x12mm
or 25x8mm needle, specific coverage chosen, plastic bag for disposal of the material used ( )
Puts the person with lesion in a comfortable position, protects their privacy and explains what will be done ( )
Uses personal protective equipment ( )
Opens the dressing material without contaminating it ( )
Removes the previous dressing using the procedure gloves which are then discarded in a plastic bag for this purpose ( )
Carefully removes adhesive tapes with 0.9% saline solution, making sure that there was no adherence onto the lesion, moistening with saline solution until it detaches, if this occurs ( )
Disposes of the dressing removed, along with gloves used, in a plastic bag for this purpose ( )
Proceeds with cleaning the lesion ( )
Uses sterile gloves or tongs to handle the lesion ( ).
Places cover recommended for treatment of the lesion ( )
Occludes the lesion with sterile equipment ( )
Applies the dressing with hypoallergenic tape or similar ( )
Discards the contaminated material in an appropriate place, organizing the environment ( )
Sanitizes hands after applying dressing ( )
3.3
Evaluates the need for debridement (chemical, mechanical, autolytic) of the necrotic and/or devitalized tissue, observed during initial or subsequent evaluation of the wound, according to the goals of
treatment and the clinical condition of the patient with skin lesion, considering:
The recommendations (purulence, local and systemic infection, presence of foreign bodies, slough, necrosis) ( )
Contraindications (infected ulcer, ischemic ulcer, neoplastic ulcer, cavity ulcer with nerve exposure, patient with coagulation disorders) ( )
3.4
Choose the type of coverage (coverage is all material, substance or product that is applied to the wound to complete of the dressing):
Recommends coverage considering:
Recommendation ( )
Side effects ( )
Presence of pain associated with skin lesion ( )
Parameters related to the goal of treating the lesion (healing or controlling signs and symptoms) ( )
Characteristics of lesion: location of wound, vitality of tissue in the bed of the wound and surrounding area, conditions of edges, characteristics and amount of exudate, odor, presence of edema,
presence of symptoms and signs of local infection, lesion area (length x width), depth of the lesion, presence of tunnels, cavities or sinus ( )
Considers availability and the cost/benefit of coverage by the service or patient in performing the treatment ( )
4
Referral and guidance to patient and family members/caregivers
4.1
Develops educational activities directed to the patient and family/caregiver, providing guidance regarding:
Diet ( )
Hygiene ( )
Hydration ( )
Skin care ( )
Risk factors for the development of lesions ( )
Clinical manifestations suggestive of worsening of lesion (pain, fever) ( )
Prevention of accident and trauma ( )
Prevention of complications ( )
Medications used in treatment ( )
Care with dressing ( )
Frequency of dressing change and encouragement of self-care( )
Carrying out activities of daily living ( )
Behavior followed in the treatment ( )
)
continues...
Acta Paul Enferm. 2014; 27(5):447-57
455
Validity of instruments used in nursing care for people with skin lesions
continuation
4.2
Identifies the need for and provides referral for the patient with skin lesion for medical evaluation (clinical evaluation or in the case of complications) ( )
When inserted into the health care team and supported by clinical care protocol, identifies the need for and provides referral of patients with skin lesions for evaluation by an interdisciplinary team of
professionals: angiologist, endocrinologist, cardiologist, physiotherapist, nutritionist, social worker, psychologist ( )
5
Record and documentation
5.1
Documenting the clinical evaluation of the patient with lesion, including information regarding:
Identification (name, age, sex, address, nationality, marital status, skin color, income, education level, occupation ( )
Emotional state ( )
Clinical history/history of disease (hypertension, diabetes, heart disease, venous/arterial insufficiency, allergies) ( )
Drugs in use ( )
Personal habits (smoking, alcohol consumption, physical activity, hours of sleep, leisure) ( )
Family history ( )
Personal hygiene ( )
Nutritional state ( )
Mobility (walking, walking with assistance, bedridden) ( )
Bladder and bowel eliminations ( )
Complaint and duration of symptoms ( )
History of current lesion and treatments performed ( )
Characterization of previous lesions ( )
Popular practice in the treatment of lesions ( )
Identification of patient’s caregiver and health institution ( )
Risk factors identified ( )
Findings of the physical examination ( )
Results of tests performed during the treatment ( )
Uses specific forms to record the evaluation of the patient with lesion ( )
Performs the nursing diagnosis ( )
Records the result of directions and guidelines in subsequent evaluations ( )
5.2
Records information about evaluation of lesion characteristics:
Type of lesion ( )
Location of lesion ( )
Measurement of length of lesion ( )
Measurement of depth of lesion ( )
Duration of lesion ( )
Characteristics of the bed of the wound ( )
Skin surrounding lesion ( )
Edge of lesion ( )
Exudate ( )
Volume of exudate ( )
Odor ( )
Exhibition of anatomical structures ( )
Evaluates the stage of tissue lesion in pressure ulcers ( )
Topical therapy performed (materials and products) ( )
Complications during application of the dressing ( )
Directions provided to the family member/caregiver and person with skin lesion (
Uses specific forms to record the characteristics and evolution of the lesion ( )
Performs the nursing diagnosis ( )
Records the result of conduct and guidance in subsequent evaluations ( )
6
Final observations
6.1
Organizes the environment:
Discards used disposable material in garbage for infectious waste, using plastic bags intended for this purpose (
Promotes the cleaning and disinfection of equipment and instruments used in care ( )
Organizes the site of care ( )
6.2
456
)
)
Sanitizes hands after care ( )
Performs simple hand hygiene with soap and water after care( )
Opens the tap and wets hands, avoiding leaning against the sink ( )
Applies in the palm of hand liquid soap sufficient to cover all surfaces of the hands ( )
Soaps palms of hands by rubbing them against each other ( )
Scrubs palm of right hand against the back of the left hand, interlacing fingers and vice versa ( )
Interlaces fingers and scrubs spaces between fingers ( )
Scrubs the back of the fingers of one hand with the palm of the opposite hand, securing fingers, in a backwards and forwards movement, and vice versa (
Scrubs right thumb with the help of the palm of the left hand, using a circular movement and vice versa ( )
Rubs the fingertips and nails of left hand against the palm of right hand, closed in a clamshell, in a circular motion and vice versa ( )
Scrubs left thumb with the help of the palm of the right hand, using a circular movement and vice versa ( )
Rinses hands, removing soap residue. Avoids direct contact of soapy hands with the tap ( )
Dries hands with disposable paper towel, beginning with the hands and then the wrists ( )
Acta Paul Enferm. 2014; 27(5):447-57
)
Costa RK, Torres GV, Salvetti MG, Azevedo IC, Costa MA
Questionnaire
1
PERSONAL IDENTIFICATION AND TRAINING/PROFESSIONAL QUALIFICATION
1.1
Age
__________ years
1.2
Sex
(
) male (
) female
1.3
Undergraduate disciplines in which you had access to the content (theory and practice) on wounds
1.4
Conducted further studies on content about wounds in addition to what was taught in course subjects
(
) No (
) Yes
1.5
Opportunity to provide care to people with wound
(
(
(
(
(
) No
) In the subjects of the course
) At work
) In field practice
) Others _____________
1.6
Observed the care of patients with wounds
(
(
(
(
(
) No
) In the subjects of the course
) At work
) In field practice
) Others _____________
1.7
Participated in extracurricular courses or training on wounds
(
(
(
(
) No
) Theoretical
) Practical
) Theoretical-practical
1.8
Hourly load of training or course
________________ hours
2
KNOWLEDGE ABOUT NURSING CARE FOR PATIENTS WITH SKIN LESIONS
2.1
What actions should be taken in the evaluation stage of a patient
with skin lesion?
1.Conduct Interview (anamnesis) and physical examination.
2.Identify risk factors and check vital signs.
3.Evaluate the lesion and check for signs and symptoms of infection.
4.Identify the need for and provide additional exams.
5.ALL OF THE ABOVE.
2.2
Which aspects should be considered when evaluating the characteristics of the skin lesion?
1.Type and duration of lesion.
2.Characteristics of the bed and edges of the lesion.
3.Presence of odor, appearance and volume of exudate.
4.Location, depth and width of lesion.
5.ALL OF THE ABOVE.
2.3
Which signs of infection should be considered when evaluating the
characteristics of the skin lesion?
1.Cool skin around the lesion, pain, exudate.
2.Necrosis, edema, exudate.
3.PAIN, ERYTHEMA, EDEMA AND HEAT, INCREASED AND PURULENT EXUDATE, ODOR.
4.Bleeding, pain, cold skin around the lesion.
5.Necrosis, pain, edema.
2.4
Which aspects should be considered when choosing the dressing to
be applied onto the skin lesion?
1.Time of evolution of the lesion, presence of infection on the lesion.
2.Lesion location and type of skin lesion.
3.Depth of the lesion, presence of pain.
4.Length of the lesion, presence of pain.
5.ALL OF THE ABOVE.
2.5
During care of the wound and surrounding skin, what is the adequate procedure to perform when applying the dressing?
1.Change the cover used in treatment without cleaning the lesion, using clean dressing technique for all types of lesions.
2.CLEAN THE LESION WITH 0.9% SALINE SOLUTION PRIOR TO CHANGING THE DRESSING.
3.Remove previous dressing with 70% alcohol or ether, clean the lesion with 0.9% saline solution, and place the cover used in the treatment.
4.Change the cover and then clean the lesion.
5.Clean open lesions with antiseptic solution, leaving uncovered.
2.6
In the initial and subsequent evaluation of the skin lesion, the nurse
should be aware of the wound characteristics that indicate the need
to perform debridement. What are these characteristics?
1.PRESENCE OF SLOUGH, FOREIGN BODIES, NECROSIS, PURULENCE, LOCAL INFECTION.
2.Cavity ulcers with nerve exposure.
3.Ulcer on terminally-ill patient.
4.Ulcer on lower limbs with presence of granulation tissue.
5.Ulcer on lower limbs in process of epithelialization.
2.7
When recommending the coverage to be used in the treatment of 1. KNOW THE RECOMMENDATION, CONTRAINDICATION, CHANGING PERIOD, COST AND BENEFIT OF THE COVER IN RELATION TO THE CHARACTERISthe lesion, what should the nurse consider?
TICS OF THE LESION TO BE TREATED.
2.Choose any cover considering the type of lesion.
3.Recommend the cover to be used in the treatment of the lesion considering only the stage in the healing process.
4.Indicate the cover that is appropriate for the treatment of all kinds of lesion.
5.All of the above.
2.8
What debriding action products are used in the topical treatment
of skin lesions?
1.Chlorhexidine, calcium alginate.
2.PAPAIN, HYDROGEL.
3.Activated charcoal, silver sulfadiazine.
4.Semi-permeable film, essential fatty acids.
5.Povidone-iodine, calcium alginate.
2.8
What guidelines should be provided to patients with skin lesions
and their relative/caregiver for continuing care?
1.Personal hygiene, nutrition, risk factors for the development and exacerbation of skin lesions.
2.Factors that interfere with the healing process, and self-care of the dressing.
3.Periodicity of application of the dressing, encouraging self-care and the performance of activities of daily living.
4.Problems in wound healing and conduct adopted and implemented in the treatment.
5.ALL THE ANSWERS CONTAIN IMPORTANT DIRECTIONS FOR PATIENTS WITH SKIN LESIONS AND THEIR FAMILY MEMBERS AND CAREGIVERS.
2.10
When completing the record and documentation of the care pro- 1. RECORD THE EVALUATION OF THE PATIENT WITH LESION, FROM THE INITIAL EVALUATION OF THE LESION AND ITS FEATURES THROUGHOUT TREATcess for a patient with lesion, what should be done?
MENT, THE DIRECTIONS PROVIDED TO THE PATIENT AND THEIR FAMILY MEMBER/CAREGIVER.
2.Record results of laboratory tests and referrals to other health professionals.
3.Document evolution of lesion throughout treatment and preventive care.
4.Record the initial clinical evaluation of the patient with skin lesion.
5.Record the initial evaluation of the lesion and its features throughout the treatment
Mark with an “X” the response that best answers the questions below:
Acta Paul Enferm. 2014; 27(5):447-57
457
Original Article
Violence against women and its consequences
Violência contra a mulher e suas consequências
Leônidas de Albuquerque Netto1
Maria Aparecida Vasconcelos Moura1
Ana Beatriz Azevedo Queiroz1
Maria Antonieta Rubio Tyrrell1
María del Mar Pastor Bravo2
Keywords
Women’s health; Primary care Nursing;
Violence against women; Domestic
violence; Family health
Descritores
Saúde da mulher; Enfermagem de
atenção primária; Violência contra a
mulher; Violência doméstica; Saúde da
família
Submitted
April 10, 2014
Accepted
June 23, 2014
Corresponding author
Leônidas de Albuquerque Netto
Afonso Cavalcanti street, 275, Rio de
Janeiro, RJ, Brazil.
Zip Code: 20211-110
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400075
458
Acta Paul Enferm. 2014; 27(5):458-64
Abstract
Objective: To analyze the consequences of intimate partner violence, from the perspective of women, as an
intervention proposal for nurses in health care.
Methods: Qualitative, descriptive and exploratory research. Theoretical framework supported by Levine’s
Nursing Theory. Sixteen women who had experienced intimate partner violence participated in the study. The
Collective Subject Discourse was used for the analysis.
Results: The consequences of violence against women were sleep disorders, improper diet, lack of energy,
body aches, bruises, abrasions, panic attacks, sadness, loneliness and low self-esteem, constituting psychoemotional and physical harm.
Conclusion: Assaults upon the integrity of women were evidenced, based on Levine’s conservational principles,
in terms of conservation of energy and conservation of structural, personal and social integrity, where the
intervention of the nurse is essential for support, promotion and rehabilitation of women’s health.
Resumo
Objetivo: Analisar as consequências da violência contra a mulher praticada pelo companheiro, na perspectiva
das mulheres, como proposta de intervenção do enfermeiro na atenção à saúde.
Métodos: Pesquisa qualitativa, descritiva e exploratória. Referencial teórico sustentado pela Teoria de
Enfermagem de Levine. Participaram 16 mulheres que vivenciaram violência pelo companheiro íntimo. Para
análise, utilizou-se o Discurso do Sujeito Coletivo.
Resultados: As consequências da violência à mulher foram distúrbios do sono, alimentação inadequada,
falta de energia, dores pelo corpo, hematomas, escoriações, síndrome do pânico, tristeza, solidão e baixa
autoestima, que determinaram danos psicoemocionais e físicos.
Conclusão: Foram constatados agravos à integridade da mulher frente aos princípios da conservação de
Levine na conservação de energia e integridade estrutural, pessoal e social, considerando a intervenção do
enfermeiro essencial ao apoio, à promoção e à reabilitação da saúde da mulher.
Escola de Enfermagem Anna Nery, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.
Facultad de Enfermería, Universidad de Murcia, Spain.
Conflicts of interest: there are no conflicts of interest to declare.
1
2
Netto LA, Moura MAV, Queiroz ABA, Tyrrell MAR, Pastor Bravo MdelM
Introduction
The saga of violence against women is recurrent and
enslaving. It strikes at autonomy, destroys self-esteem and reduces Quality of Life, with consequences for personal, family and social structuring. The
aggressions committed are threatening, and generally associated with disturbing social problems,
such as unemployment, marginalization, social inequalities and the use of alcohol and drugs, creating
an impact on the morbidity and mortality of this
population. It contributes to loss of Quality of Life,
increased health care costs and school and work absenteeism, in addition to being one of the most significant ways in which personal, family and social
structures are broken down.(1)
Violence is any act of aggression or negligence
toward a person, group or community, which produces or can produce psychological damage, physical harm or sexual suffering, and includes threats,
coercion or arbitrary deprivation of liberty, whether
in a public or private setting.(2,3)
To understand the complexity of violence
against women, it is necessary to uncover its structures involving the concept of gender. Gender is understood as a historical and sociocultural construct,
which assigns roles and behaviors to the sexes. For
women, it is defined as passivity, fragility, emotion
and submission, and for men, activity, strength,
reason and domination. The dimension of gender
is structured as a power relationship, resulting in a
usurpation of the body of the other, and is generally
framed between men and women.(4)
Research conducted in Brazil by the Perseu
Abramo Foundation, on violence against women
and gender relations in public and private places,
estimated that of the 2365 women from 25 states in
the country, 34% had been subjected to violence in
the domestic realm.(5) Every two minutes, five women are violently assaulted. Violent acts result in the
loss of one year of healthy life, for every five years of
being subjected to aggression.(6)
This violence, regardless of the gender perspective, is currently permeated by various physical,
psychological and sexual aspects, and is considered
a public health problem, constituting a violation
of human rights.(7) Interventions for solving this
problem should not necessarily dispense with the
clinical approach, but measures need to be taken
to promote the conservation of health. This is because clinical actions are not sufficient for addressing all the varied dimensions of the problems and
the health needs of women. The strengthening of
cooperation between sectors and collective action is
essential for overcoming the helplessness reported
by many health professionals in situations involving violence.(8) Such actions, in health/nursing, require a broader approach, emphasizing intervention
proposals for the follow-up care of these women in
health facilities, in social support networks and with
comprehensive, humanized care.
Women, being the primary target of this type
of violence, have received attention from governmental authorities (national and international) and
health professionals, especially nurses who, in their
jobs and any work environment, encounter this situation, which requires specific knowledge and skills
for providing care.(9)
Many theories have been proposed in Nursing, but in terms of battered women, a theoretical framework was sought that provides a comprehensive view of the individual. On the basis of
this premise, the Theory of Nursing of Myra Strin
Levine was used,(10) seeking connections with the
comprehensive care of women’s health. Levine’s
conceptual model characterizes the individual as a
dynamic whole, in constant interaction with his or
her environment, and focuses on patients who enter
a health establishment in need of care due to their
altered state of health.
The discussion here is guided by principles related to the debilitated health of women who suffer
intimate partner violence in a private realm, hidden
from the public. This theory presents sickness as a
stressful situation in which the individual attempts
to adapt to his or her altered state of health. This
adaptation is manifested by an organic reaction,
which includes negative changes in the behavior of
the body or degeneration in the levels of its functioning. The purpose of this adaptation is so that
the individual can regain a state of complete independence.(11)
Acta Paul Enferm. 2014; 27(5):458-64
459
Violence against women and its consequences
The nurse provides the woman with appropriate
care, bearing in mind her wholeness and encouraging her to participate in the restoration of her
well-being. The function of the nurse is to transmit
knowledge and strength, motivating the woman to
withdraw from her debilitating situation and find a
more independent milieu in order to survive.(10)
The nurse’s expertise should assist in the process of maintaining wholeness and personal, family
and social structure, through a minimum expenditure of energy, supporting and promoting social
rehabilitation and insertion. The core of this theory
has three theoretical pillars: adaptation, conservation and integrity. In this research, the dimension
of conservation of health was addressed, which encompasses four principles: (1) conservation of energy, (2) conservation of structural integrity, (3) conservation of personal integrity and (4) conservation
of social integrity.(11)
The conservation of energy is characterized by
activities necessary for supporting life, such as those
involving growth and development. The conservation of structural integrity focuses on experiences
with injuries, sickness processes and inflammatory
and immunological responses. The conservation
of personal integrity focuses on the sense of being
– defined, protected and described by its essence –
wherein each person is unique, exclusive and complete. In turn, the conservation of social integrity
involves defining the person within a context that
extends beyond the individual, where each one is
defined through their relationships. Each person’s
identify is connected to family, community, culture,
ethnicity, religion and education.(10)
The applicability of Levine’s theory provided
support to this research through the principles of
conservation, which underlie the interventions of
nurses when faced with the problem of violence
in the care of women. It can be argued that the
current care model still operates on the basis of
rationality and reductionism, which reinforces
the biomedical model in the care administered by
health professionals.(12)
The scientific literature uncovered studies that
show the consequences of violence upon women’s
health as problems common to physical and psy-
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Acta Paul Enferm. 2014; 27(5):458-64
cho-emotional integrity.(5,12-14) As a weakness in
knowledge production, it was noted that few studies use the Levine Theory approach, from the perspective of conservation of health, in relation to
energy and structural, personal and social integrity.
The objective of this study was to analyze the
consequences of intimate partner violence, from the
viewpoint of women, based on Levine’s Theory of
Nursing, as an intervention approach for nurses in
the comprehensive care of women’s health.
Methods
Qualitative, descriptive and exploratory research,
carried out in the Centro de Referência e Atendimento à Mulher em Situação de Violência Doméstica - CR Mulher (a reference care center for women
in situations of domestic violence), in the metropolitan region of Rio de Janeiro, state of Rio de Janeiro, Brazil. This center uses focus groups, frequent
meetings and educational dynamics in an effort to
restore the self-esteem of abused women.
The participants were women, over the age of
18, who had suffered physical, psychological or sexual violence at the hands of an intimate mate, attended focus group meetings and voluntarily signed
a Free and Informed Consent Form.
Data were collected between June and September of 2012. Sixteen of the 32 women receiving care
at CR Mulher were interviewed. The empirical profile was limited by the saturation of data and the
diversity of this universe.
Individual interviews, with a semi-structured
script, were conducted in a room reserved at this facility in order to collect data. Permission was given
to record them and they lasted on average 40 minutes. There was a formal presentation with respect
to the ethical criteria, the issue of confidentiality
and the right to stop participating in the research,
without this in any way affecting the care being received. The first step was getting to know the socio-demographic profile of the female participants.
The analysis of the results was based on the
method of Collective Subject Discourse, which entailed organizing the verbal empirical data obtained
Netto LA, Moura MAV, Queiroz ABA, Tyrrell MAR, Pastor Bravo MdelM
from the testimonies. To prepare the Collective
Subject Discourse, it was necessary to build two
methodological figures: Key Expressions and Central Ideas. The first consists of literal transcriptions
of the discourse that reveal the essence of the testimonies. “Central Ideas” is a linguistic expression
that describes, in a more authentic way, the meaning of each homogeneous set of Key Expressions.
As a data processing technique, Collective Subject
Discourse suggests a collective person speaking as
though an individual subject from the discourse.(15)
In the construction of this Collective Subject Discourse, isolated parts of the testimonies
were added in, to form a discursive whole, where
each party could be recognized as a constituent
within the whole and vice versa.(15) When a response had more than one Collective Subject
Discourse, it was differentiated from the others using difference and antagonism or complementarity criteria, adhering to a consistency of
ideas. Lastly, repetitions and particularities were
removed from the individual discourses in order
to structure the Collective Subject Discourse,
which imparted naturalness and spontaneity to
the collective thought.
The development of this study complied with
national and international ethical guidelines for research involving human beings.
Results
People cannot be understood outside the context
of time and place in which they interact and are
never isolated from the influence of everything
happening around them, according to Levine.
Human beings are influenced by their immediate
circumstances and undergo experiences throughout their entire lives, which leave marks on their
minds, bodies and spirits.
Of the 16 women who participated, nine were
from 25 to 44 years of age. In terms of marital
status, eight were separated or divorced from their
mates. Insofar as education, ten women had completed 12 years of education. Of the participants,
11 had paid activities, three were housewives and
two were retired. Half of them were white, seven
were brown and one was black.
Four Central Ideas emerged from the data analysis related to the consequences of violence, according to the principles of conservation of health in
Levine’s Nursing Theory, described in the Collective Subject Discourses, based on the testimonies of
the women.
The first Central Idea shows the consequences
of violence that undermine the conservation of
energy of women:
My sleep is restless; I wake up several times a night.
I feel worn down, I’m tired, and my body aches. When
he [the mate] beat me, I didn’t eat for four days, and
I had to breastfeed my son. I feel weak and without
any energy. I’ve lost weight. I’m constipated and have a
stomach ache. (CSD 1)
The consequences of violence that undermine
the conservation of structural integrity are seen in
the second Central Idea, stemming from the second discourse:
The beatings make me nervous and I eat a lot. I’m
overweight, but I can’t stop eating. I had bruises on my
arms. When he [the mate] tried to choke me, he left
marks on my neck. He kicked me and I had purple
marks on my back. He left me all bloody and I had to
be hospitalized for a while. I started smoking again,
something I didn’t want to do. (CSD 2)
The third Central Idea shows the consequences
of violence that undermine the conservation of personal integrity of women:
I was destroying myself, I hated myself. I felt I
wasn’t good for anything and I would say to myself,
‘what good am I if I can’t even make my husband like
me?’ The psychological scars are the worst. You feel incapable and helpless. You don’t want others to know
you’re experiencing violence. You get very disturbed by
the mean words your husband says to you. I have low
self-esteem. (CSD 3)
The consequences of violence that undermine
the conservation of social integrity can be seen in
the fourth Central Idea:
When he [the mate] would say he was going to
do something bad to my family I’d go crazy. I’d rather
he would kill me. My greatest regret is that I stopped
working. I’ve lost my trust in men and think they’re
Acta Paul Enferm. 2014; 27(5):458-64
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Violence against women and its consequences
all going to do the same thing and I back away. I’ve
lost interest in everything. I stopped taking care of
myself and didn’t leave the house. I stayed holed up
in my room and didn’t want to see or talk to anyone.
(CSD 4)
Discussion
The limitations of these results involve the employability of the methodology of Collective Subject
Discourse as a discursive methodological strategy,
which enabled a relatively limited understanding of
a set of representations that comprised the specific
imaginary construct of a group of women who had
experienced violence.
Our results enable nurses to develop intervention initiatives for the care of women in situations
of intimate partner violence, based on concepts
from Levine’s Nursing Theory, related to the consequences of aggressive acts of violence against
their health.
The characteristics of these women were similar
to the profile of the female population in situations
of violence in other studies.(16-20) The majority were
young, white, adult women of reproductive age,
who were married or in common law marriages,
had completed high school and were working in the
job market. The aggressors were predominantly the
intimate partner.
The negative impact on the women’s conservation of energy was characterized by sleep and rest
disorders, physical fatigue, constant tiredness, inadequate nutrition, weakness, lack of energy and
disorders of the intestinal tract. Conservation of
energy is a protective factor for the integrity of the
functional system of individuals, which addresses
their health from a holistic angle.(10) The symptoms
resulting from violent relationships were reflected
in insomnia, headaches, fatigue, constipation and
weight loss, among others. The effects of spousal
violence occur due to its repetition, in the form
of psychic traumas of moderate or severe intensity, without being tied to a medicinal approach for
problems that, generally, have a political or sociocultural nature.(21)
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Acta Paul Enferm. 2014; 27(5):458-64
In the care provided by nurses to women in situations of violence, as far as conservation of energy,
an anamnesis and physical examination are essential
for checking the following: vital signs, nutritional
assessment related to frequency and availability of
food, physical exercise, bowel and bladder elimination pattern and evaluation of menstrual cycles. The
focus of these parameters was to identify aspects of
energy conservation and expenditure related to the
suffering, leading the women to seek nursing care.
In the discourse of the participants, injuries
were referred to, such as bruises, abrasions, dislocations and lacerations. In regard to disease processes and inflammatory and immunological responses, they reported body pain, obesity, panic
attacks, bouts of gastritis and ulcers. Conservation
of structural integrity is the process of restoration
and maintenance of the organism, which has defense mechanisms to protect the individual against
possible tissue losses, thereby preventing the entry
of microorganisms, avoiding a physical breakdown
and promoting recovery.(10) Among the damages
arising from violence to women’s health are mutilations, fractures, sex-related problems and obstetric
complications.(22) Violence also leads to a higher
risk of accidents and smoking. These women generally overuse medication, especially antibiotics
and anti-inflammatory drugs.(23)
In the care administered by nurses to women,
in terms of conservation of structural integrity, it is
essential in the physical examination to inspect and
observe skin integrity, to check for the presence of
skin lesions. At the time of the anamnesis and clinical background, women may reveal the disease processes experienced and inflammatory and immunological responses, and referrals should be made to
support networks.
The personal consequences for the participants
in the study were feelings of annihilation, sadness,
discouragement, loneliness, stress, low self-esteem,
inability, powerlessness, anger and worthlessness.
The principle of conservation of personal integrity
is the preservation of individuality and privacy.(10) A
study conducted in hospitals indicated the following effects of violence upon women: irritability, decreased self-esteem, professional insecurity, sadness,
Netto LA, Moura MAV, Queiroz ABA, Tyrrell MAR, Pastor Bravo MdelM
loneliness, anger , lack of motivation, relationship
difficulties, desire to quit their jobs and family relationship difficulties.(24)
With respect to the conservation of personal
integrity of women, nurses are responsible for ensuring their privacy and involving them in the decision-making process, providing an embracing environment, attentive listening and sensitivity toward
the problem. However, women who share their life
experiences with others also preserve their identity as unique beings. Human beings have a public
persona and a private persona, details of which are
often not divulged even to those closest to them.
When these women recognize, in the nurse, a professional willing to help and guide them, this facilitates the process of strengthening their self-esteem
and autonomy.
The women expressed fear that their mates
could cause harm to their families, especially their
children; they regretted having quit outside jobs;
and they found it difficult to engage in relationships with other people due to lack of interest. The
conservation of social integrity is based on the fact
that all individuals live in society and their behavior is related to social groups.(10) In a state of
weakened health, these women feel lonely, and
think back to family and friends, with these being
essential to their recovery. The nurse, within social
support networks, has the role to encourage and
help reinsert the women into their new context,
understanding them as beings who have been dominated, exploited and suffered, and whose story is
shrouded in subjectivity.(25)
In terms of conservation of social integrity, the
information obtained by nurses is relevant for establishing personal possibilities and social and family resources, building alternatives and actions that
strengthen bonds of care and support, and expand
the support networks related to security, justice and
social assistance.
Conclusion
In this study, the analysis of the consequences of
intimate partner violence found links with the
principles of the conservation of health in Levine’s
Nursing Theory, in relation to the undermining of
conservation of energy and structural, personal and
social integrity. The results were characterized by
physical, psychological and emotional disturbances, influencing the conservation and integrity of
the health of these women in a way that had a degrading, aggressive and destructive effect on their
self-esteem and state of complete independence.
There is a need for inclusion of nurses in the comprehensive care of women’s health and in humanistic care, as well as in embracing these women, in
order to strengthen their autonomy and self-esteem.
Through Levine’s Nursing Theory, it was possible to
expand knowledge in the field of nursing care with
possibilities for intervention and actions focused on
reducing the impact of violence against women.
Acknowledgments
The authors thank the Coordination for the Improvement of Higher Education Personnel (CAPES)
for granting a scholarship during the 16 months
of the master’s program at Escola de Enfermagem
Anna Nery, Universidade Federal do Rio de Janeiro,
between 2011-2013.
Collaborations
Netto LA worked on the preparation of the project, concept and design of the research, literature
review, data collection and analysis, interpretation
of the results and drafting of the article. Moura
MAV contributed with guidance and direction of
the article through a critical relevant review of its
intellectual content. Queiroz ABA, Tyrrell MAR
and Bravo MMP collaborated on the final approval
of the version to be published.
References
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Departamento de Análise de Situação de Saúde. Viva: instrutivo
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3. Kopcavar NG, Svab I, Selic P. How many Slovenian family practice
attendees are victims of intimate partner violence? A re-evaluation
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4.Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde.
Departamento de Ações Programáticas Estratégicas. Prevenção e
tratamento dos agravos resultantes da violência sexual contra mulheres
e adolescentes: norma técnica [Internet]. 3. ed. atualizada e ampliada.
1. reimpressão. Brasília, DF: Ministério da Saúde; 2012[cited 2014
Abr 7]. Série A. Normas e Manuais Técnicos. Série Direitos Sexuais
e Direitos Reprodutivos; Caderno n. 6. Available from: http://bvsms.
saude.gov.br/bvs/publicacoes/prevencao_agravo_violencia_sexual_
mulheres_3ed.pdf.
5. Fundação Perseu Abramo. [Brazilian women and gender in public and
private spaces] [Internet]. 2010[cited 2014 Abr 7]. Available from: http://
www.fpabramo.org.br/sites/default/files/pesquisaintegra.pdf. Portuguese.
6. Acosta DF, Gomes VL, Barlem EL. [Profile of police reports related to violence
against women]. Acta Paul Enferm. 2013; 26(6): 547-53. Portuguese.
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violence and sexual violence against women. WHO clinical and policy
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8. Guedes RN, Fonseca RM, Egry EY. [The evaluative limits and
possibilities in the family health strategy for gender-based violence].
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9. Morais SC, Monteiro CF, Rocha SS. [Nursing care for sexually violated
women]. Texto & Contexto Enferm. 2010; 19(1): 155-60. Portuguese.
10.Levine ME. Conservation and integrity. In: Parker ME, organizadora.
Nursing theories in practice. New York: National League for Nursing;
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de enfermagem: fundamentos para a prática profissional. Porto Alegre
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discurso do sujeito coletivo. In: Lefèvre F, Lefèvre AM. O discurso do
sujeito coletivo: um novo enfoque em pesquisa qualitativa. Caxias do
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2014 Abr 7]. Disponível em: http://www.paho.org/bra/index.
php?option=com_content&view=article&id=3200:saude-brasil2011-uma-analise-da-situacao-de-saude-e-a-vigilancia-da-saudeda-mulher&catid=758:bra-principal&Itemid=347.
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Original Article
Breastfeeding self-efficacy: a cohort study
Autoeficácia na amamentação: um estudo de coorte
Erdnaxela Fernandes do Carmo Souza1
Rosa Áurea Quintella Fernandes2
Keywords
Maternal-child nursing; Obstetrical
nursing; Breastfeeding; Infant nutrition;
Self-efficacy
Descritores
Enfermagem materno-infantil;
Enfermagem obstétrica; Aleitamento
materno; Nutrição do lactente;
Autoeficácia
Submitted
April 29, 2014
Accepted
July 29, 2014
Corresponding author
Rosa Áurea Quintella Fernandes
Teresa Cristina square, 229, Guarulhos,
SP, Brazil. Zip Code: 07023-070
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400076
Abstract
Objective: Evaluate the clinical use of the Breastfeeding Self-Efficacy Scale as predictive of early weaning and
verify if women who had higher self-efficacy scores breastfed for longer periods.
Methods: Cohort study developed with 100 postpartum mothers. Research instrument used: Breastfeeding
Self-Efficacy Scale-Short Form. The feeding was monitored on the 7th, 15th, 30th, 45th and 60th day, by
phone.
Results: The mean duration of exclusive breastfeeding was 53.2 days (SD 14.2). Most mothers (82.3%) had
scores compatible with high self-efficacy for breastfeeding, none had low efficacy. There was no statistically
significant difference in the comparison of mean duration of exclusive and non-exclusive breastfeeding, with
the scores of medium and high efficacy.
Conclusion: Findings did not enable the confirmation of the use of the scale as a predictor of risk of early
weaning. No relation was observed between higher scores of high efficacy and longer periods of exclusive
breastfeeding.
Resumo
Objetivo: Avaliar o uso clínico da Escala de Autoeficácia na amamentação como preditiva do desmame precoce
e verificar se as mulheres que obtiveram maiores escores de autoeficácia amamentaram por mais tempo.
Métodos: Estudo de coorte com 100 puérperas. Instrumento de pesquisa utilizado: Breastfeeding Self-Eficacy
Scale-Short Form. O aleitamento foi monitorado no 7º, 15º, 30º, 45º e 60º dia, por telefone.
Resultados: A média de aleitamento materno exclusivo foi de 53,2 dias (DP 14,2). A maioria das mães
(82,3%) obteve escores compatíveis com alta autoeficácia para a amamentação, nenhuma apresentou baixa
eficácia. Não houve diferença estatisticamente significativa na comparação da média de tempo de aleitamento
exclusivo e não exclusivo, com os escores de média e alta eficácia.
Conclusão: Os resultados não permitiram confirmar a utilização da escala como preditiva de risco de desmame
precoce. Não se observou relação entre maiores escores de alta eficácia e maior tempo de aleitamento
materno exclusivo.
Hospital Samaritano, São Paulo, SP, Brazil.
Universidade Guarulhos, Guarulhos, SP, Brazil.
Conflicts of Interest: there are no conflicts of interest to declare.
1
2
Acta Paul Enferm. 2014; 27(5):465-70
465
Breastfeeding self-efficacy: a cohort study
Introduction
The World Health Organization (WHO) and the
United Nations Children’s Fund (UNICEF) have
undertaken efforts to protect, promote and support exclusive breastfeeding (EBF), so that mothers are able to establish and keep it for the first
six months of life of the baby.(1) But this reality
in Brazil is still far from being achieved, since the
prevalence of exclusive breastfeeding in the first 6
months is only 41%, according to the latest survey
conducted in the Brazilian capitals and the Federal
District (DF).(2)
Breastfeeding (BF) is considered, worldwide,
one of the fundamental pillars for promoting and
protecting the health of children and its social impact can be quantified through the reduction of
medical consultations, hospitalizations and medical
treatments, since the child in EBF has lower risk
of becoming ill.(3) The obstacles to breastfeeding are
numerous, but generally the allegations to its abandonment involve myths and misinformation, even
among women with higher socioeconomic status,
which confirms the importance of guidance and
interventions from healthcare professionals in supporting nursing mothers.
The advancement of public health policies
in encouraging BF is increasingly evident.(4) The
outlining of these actions is notorious and covers
a great part of the women using the public health
network. On the other hand, women who do not
use this network and are assisted in private institutions not always can count on professional support
to help them during the difficulties in BF, especially
after discharge.
In this context, it becomes necessary to reformulate strategies, mainly from the private health
network, to promote, protect and support EBF,
reinforcing the adherence of women who are able
to be assisted in the private health network. These
mothers generally receive breastfeeding support
while hospitalized, however, almost no institution
has resources available to maintain this support after delivery in the domicile, or has breastfeeding
outpatient services. These deficiencies may favor
early weaning in this segment.
466
Acta Paul Enferm. 2014; 27(5):465-70
Therefore, the institutions and professionals in
the private health network are faced with the challenge of implementing breastfeeding care practices
during the prenatal, delivery and postpartum periods, mainly because of the need for professional
support mothers have in the first days after birth,
a phase that is a defining moment to overcome a
series of obstacles to breastfeeding and to avoid its
abandonment.
Following up mother and baby at a breastfeeding outpatient service, until the tenth day after
discharge, represents a strategy that can contribute to reverse an inadequate indication of formula
supplementation, or even a possible breastfeeding
interruption.(5) Unfortunately, there are only a few
private health services that promote monitoring of
both mother and child after discharge.
Learning the willingness of mothers to breastfeeding can be a way to predict whether they will
maintain the recommended breastfeeding period,
which would help professionals to identify difficulties and weaknesses and establish supportive
interventions. The application of a breastfeeding
self-efficacy scale could point out the mothers with
more weaknesses, in the aspects required in the
process of breastfeeding, and allow interventions
during provision of nursing care that occurs after
childbirth, intending to provide support for successful breastfeeding.
A study associated longer periods of EBF with
the determination of the mothers to breastfeed, and
it recommended attention from health professionals
to the absence of mothers’ determination to breastfeeding, so that interventions can be performed to
consolidate this practice.(6)
The objective of this study was to evaluate the
clinical use of the Breastfeeding Self-Efficacy Scale
as predictive of early weaning and to verify if the
women who had higher self-efficacy scores breastfed
longer than those who had lower scores.
Methods
This is a cohort study conducted in a large private
hospital, located in an upscale neighborhood of the
Souza EF, Fernandes RA
city of São Paulo. The sample was defined by convenience and comprised 100 postpartum women who
gave birth in the period between November 2010
and April 2011, and who met the following inclusion criteria: being in postpartum (48-72 hours
after delivery); having agreed to participate in the
study for up to 60 days after the baby’s birth; having
a landline or mobile phone number; being breastfeeding exclusively during hospitalization.
The survey instrument used was the Escala de
Autoeficácia na Amamentação, the Brazilian version
of the Breastfeeding Self-Eficacy Scale-Short Form
(BSES-SF). This scale has been validated in Brazil
by Dodt in 2008, who applied it in a public hospital in Ceará.(7) This instrumentis clinically useful for
nurses to apply in the postpartum period, mainly
due to short hospital stays. The scale helps to recognize mothers who are likely to succeed in breastfeeding, providing them with positive reinforcement, as well as those who may need interventions
before discharge, in order to provide appropriate
and effective assistance.(8)
The scale consists of three dimensions (magnitude, generalization and strength) and is based on
four sources of information (personal experience,
observational or vicarious experience, verbal persuasion and emotional and physiological state).(9)
In each rated item, the woman gave a score ranging from 1 to 5 points (1 - Strongly disagree 2 Disagree, 3 - Sometimes agree, 4 - Agree and 5 Strongly agree).
For data collection, the women were interviewed once during hospitalization and after childbirth they were contacted by telephone on the 7th,
the 15th, the 30th, the 45th and the 60th day to monitor breastfeeding continuity.
For statistical analysis, the data were compiled
and analyzed using the SPSS (Statistical Package
for Social Sciences), version 16.0. The Kolmogorov-Smirnov test was used to evaluate the adhesion
of the dependent and independent continuous variables to the normal distribution curve. The Pearson’s correlation coefficient was calculated, and
ANOVA was employed to compare the duration of
breastfeeding among women with different degrees
of self-efficacy in breastfeeding. The chi-square test
was used for the association between problems in
each stage of BF monitoring. In all analyzes, the level of significance used was p ≥ 0.05.
The study development complied with all national and international ethical guidelines for research involving human subjects.
Results
The sociodemographic profile of the mothers who
participated in the study can be outlined as follows:
mean age of 32.8 years, ranging from 17 to 44
years; most of them (94.6%) are married, Catholics
(53.1%), have paid working activities (90%) and
completed higher education (70%). A total of 47%
were primipara, 43% secundipara, 87% of the deliveries were caesarean and 95.3% reported not having received any guidance on breastfeeding during
prenatal care.
The mean time of EBF was 53.2 days (SD 14.2),
ranging from 15 to 60 days (Table 1).
Tabela 1. Table 1. Frequency of feeding during the postpartum
periods analyzed
Days after birth
Type of feeding
7thDay
15thDay
30thDay
45thDay
60thDay
n(%)
n(%)
n(%)
n(%)
n(%)
100(100.00)
92(92.00)
84(84.00)
81(81.00)
79(79.00)
Supplemented
-
8(8.00)
15(15.00)
14(14.00)
15(15.00)
Formula
-
-
Exclusive
1(1.00)
5(5.00)
6(6.00)
At the start of monitoring, in the seventh postpartum day, 100% of the women practiced EBF.
However, by the 15th day, 8% of mothers had
introduced a complement, therefore practicing
mixed feeding. On the 30th day, 15% of mothers supplemented breastfeeding with formula and
1% had weaned the baby. Exclusive breastfeeding
showed a progressive decline reaching 79% at 60
days (Table 2).
Acta Paul Enferm. 2014; 27(5):465-70
467
Breastfeeding self-efficacy: a cohort study
Table 2. Scores obtained by mothers in the application of
breastfeeding self-efficacy scale
Score of self-efficacy: (n= 130)
n(%)
Low (14-32)
-
Moderate (33-51)
23(17.70)
High (52-70)
107(82.30)
Total
130(100.00)
BSES-SF
Mean (SD)
Median (Q1-Q3)
Total Score
60.57(5.07)
62.00(58.00-64.75)
The score of the breastfeeding self-efficacy scale
varies from 14 to 70 points. When the respondent
obtains between 14 and 32 points, she is considered
to have Low efficacy; between 33 and 51, Moderate; and between 52 and 70, High efficacy.
Most mothers (82.3%) had scores compatible
with high self-efficacy for breastfeeding (52-70
points) and there was no mother with low efficacy
(Table 3).
Table 3. Comparison of the duration of breastfeeding with the
mean scores of the breastfeeding self-efficacy scale
Breastfeeding Self-efficacy
Moderate
High
Mean (SD)
Mean (SD)
Exclusive breastfeeding
56.10(10.6)
53.00(14.5)
0.547
Non-exclusive breastfeeding
60.00(0.0)
58.70(5.3)
0.487
Breastfeeding duration
p-value
SD - Standard deviation
The relationship between self-efficacy and the
duration of breastfeeding was assessed by measuring
the correlation of the scale scores (BSES-SF) and
the feeding time in days, as well as by comparing
the time of breastfeeding among women with moderate and high self-efficacy.
There was no statistically significant difference
in the comparison of mean time of exclusive and
non-exclusive breastfeeding, within moderate and
high efficacy scores.
468
Acta Paul Enferm. 2014; 27(5):465-70
Discussion
The limitations of the findings of this study are
related to the fact that the sample was originated
from only one service with specific characteristics,
and the monitoring of EBF was performed only up
to the 60th day after delivery.
In the sample studied, the findings did not enable to verify the self-efficacy scale as predictive for
early weaning. On the other hand, its clinical applicability was verified as a reliable instrument to assess
the perception of mothers about their breastfeeding self-efficacy, enabling professionals to identify
mothers who are susceptible to succeed in breastfeeding, as well as those who may need intervention
before hospital discharge.
The sociodemographic profile of the participants is consistent with the neighborhood where
they reside, economically differentiated. The percentage of cesarean sections (87%) is high, even
for an institution that primarily assists patients
using private health network, a result compatible
with a 2010 study which identified a 63.6% rate
of surgical births with an increasing trend, in these
services.(10)
The need for implementation of strategies that
enable women, assisted in the private network, to
have access to guidance on breastfeeding is evidenced by the high percentage of pregnant women
who received no information on the subject.
The mean duration of EBF was 53.2 days.
This result is consistent with that identified in
the last national survey of prevalence of breastfeeding in Brazilian state capitals and the Federal
District, held in 2008, which identified a median
EBF period of 54 days.
The expectation was to find longer periods of
EBF, since the mothers not only obtained moderate and high scores of breastfeeding self-efficacy,
but also belong to a more privileged social class and
presented high level of schooling, points considered
important to maintain EBF.
The monitoring of EBF began on the 7th day
after delivery and 100% of women were exclusively
breastfeeding their children. However, EBF showed
a progressive decline, reaching 79%, at 60 days.
Souza EF, Fernandes RA
A study that monitored EBF up to 180 days after
delivery revealed a higher number of abandonment after 60 days, and the percentage of mothers who exclusively breastfed up to the 60th day (70.4%) is slightly
lower than that found in the present study (79%).(11)
Rates of exclusive breastfeeding in Brazil are on
a rise, but still below what is recommended by the
WHO, which is 180 days. The percentage of 79%
of children being exclusively breastfed, identified
in this study, can be considered adequate, since the
WHO attributes this concept when 50% to 89%
of children under six months of age are exclusively
breastfed.(11) The application of the scale allowed to
identify that mothers presented high and moderate
efficacy and none of them obtained results consistent with low self-efficacy.
These results signaled that the mothers who
participated in this study would probably maintain
EBF for longer periods, a fact that was not consolidated at the end of monitoring.
A studythat used the same scale (Short Form)
in 294 postpartum women also noted the absence
of mothers with low efficacy. However, since the
mothers were not followed up, it was not possible
to compare the results.(7)
The comparison of the mean time of exclusive
and non-exclusive breastfeeding, with the scores of
moderate and high efficacy showed no statistically
significant difference, which indicates that, in this
study, the self-efficacy of the mothers did not influence the duration of breastfeeding.
Nevertheless, these results differ from those of
the original study, conducted in Canada, which
evaluated maternal confidence in breastfeeding
among 130 Canadians and found that the higher
the BSES score, the greater the likelihood of the
women maintaining exclusive breastfeeding at 6
weeks postpartum (p < 001).(12)
Another longitudinal studycarried out in Australia with 300 pregnant women evaluated the influence of changeable factors in prenatal and breastfeeding duration. The scale was applied in the last
trimester of pregnancy, at the 1st week postpartum
and at baby’s 4 months of life, and the results revealed that mothers who intended to breastfeed for
less than 6 months were 2.4 times more likely to
stop BF in 4 months than those who intended to
breastfeed for more than 12 months. Similarly, the
association of the BSES score with the duration of
exclusive breastfeeding showed that mothers with
higher self-efficacy scores were more likely to breastfeed longer, both one week and four months postpartum, than those presenting low self-efficacy in
feeding (p <0.05).(13)
Conclusion
The results did not confirm whether the scale may
be used as a predictor of risk of early weaning. In
addition, no relation between greater scores of high
efficacy and longer periods of exclusive breastfeeding was observed.
Collaborations
Souza EFC and Fernandes RAQ contributed to the
project design, analysis and interpretation of data,
drafting of the article, critical revision of the relevant intellectual content and final approval of the
version to be published.
References
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index.php/revista/article/view/579/pdf.
8. Dennis CL. The breastfeeding self-efficacy scale: psychometric
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Acta Paul Enferm. 2014; 27(5):465-70
Original Article
Risks related to drug use among
male construction workers
Risco relacionado ao consumo de drogas em
homens trabalhadores da construção civil
Aroldo Gavioli1
Thais Aidar de Freitas Mathias2
Robson Marcelo Rossi2
Magda Lúcia Félix de Oliveira2
Keywords
Substance-related disorders; Mass
screening; Primary care nursing;
Occupational health nursing; Workers
Descritores
Transtornos relacionados ao uso
de substâncias; Programas de
rastreamento; Enfermagem de atenção
primária; Enfermagem do trabalho;
Trabalhadores
Abstract
Objective: To identify the prevalence of risk related to drug use among workers of a construction company and
to evaluate how it relates with sociodemographic variables.
Methods: A cross-sectional study conducted with 418 workers who were given the Alcohol, Smoking and
Substance Involvement Screening Test. Multinominal logistic regression was used as a measure of association.
Results: Tobacco, alcohol, cannabis, cocaine and inhalants were the most used drugs. Moderate and high
risks were related, respectively, to the use of tobacco (32.5% and 5.7%), alcohol (26.8% and 6.9%), cannabis
(2.6% and 2.4%) and cocaine (1.2% and 0.5%).
Conclusion: Tobacco and alcohol were the main drugs used by workers. The level of risk related to the use of
tobacco, alcohol, cannabis and cocaine were high when compared to that of the general population.
Resumo
Submitted
May 6, 2014
Accepted
June 23, 2014
Objetivo: Identificar prevalência do risco relacionado ao consumo de drogas entre trabalhadores de uma
empresa de construção civil e avaliar sua associação com variáveis sociodemográficas.
Métodos: Estudo transversal realizado com 418 trabalhadores que responderam ao Alcohol, Smoking
and Substance Involvement Screening Test. Utilizou-se a regressão logística multinomial como medida de
associação.
Resultados: Tabaco, álcool, maconha, cocaína e inalantes tiveram prevalência de uso elevada. Riscos
moderado e elevado estiveram relacionados, respectivamente, aos consumos de tabaco (32,5% e 5,7%),
álcool (26,8% e 6,9%), maconha (2,6% e 2,4) e cocaína (1,2% e 0,5%).
Conclusão: Tabaco e álcool foram as principais drogas utilizadas pelos trabalhadores. Níveis de risco
relacionados ao consumo de tabaco, álcool, maconha e cocaína foram elevados quando comparados aos da
população em geral.
Corresponding author
Aroldo Gavioli
Mandacarú Avenue, 1590, Maringá, PR,
Brazil. Zip Code: 87083-240
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400077
Hospital Universitário Regional de Maringá, Maringá, PR, Brazil.
Universidade Estadual de Maringá, Maringá, PR, Brazil.
Conflicts of interest: there are no conflicts of interest to declare.
1
2
Acta Paul Enferm. 2014; 27(5):471-8
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Risks related to drug use among male construction workers
Introduction
The relationship between work and drug use is still
little understood in Brazil, where the problem is in
fact underreported.(1) Studies point to an increase of
violent events in the workplace when there is drug
use among workers.(2) Currently, such use is recognized as the main responsible factor for traumatic
injury, and the burden imposed on the Brazilian
health system by health problems results in elevated
social and economic costs.(3,4)
Being a common phenomenon of the workplace, drug use results in increased illness, work-related injuries, absenteeism and disability, all of
which contribute to reducing productivity. In this
context, construction work is a business activity of
great importance in the global economic scenario. However, together with its importance in the
economy, it also presents a harsh reality regarding
working conditions: it is considered one of the most
hazardous activities or work worldwide and in Brazil, it is responsible for the highest rates of fatal and
non-fatal work-related injuries and of years of potential life lost.(5,6)
A case study on severe work-related accidents
that happened in the state of Paraná, Brazil, and
were recorded in the Brazilian Notifiable Diseases
Information System (SINAN, as per its acronym in
Portuguese) from 2007 to 2010, found that approximately 14% of total severe and fatal work-related
accidents had happened among construction workers.(7) As responsible for this high rate of work-related accidents among this professional category, we
emphasize the elevated level of occupational risks,
stress and psychic suffering related to the temporary
nature of the job, high staff turnover and precarious
work contracts.(6,8)
A study that aimed at studying discrimination
and social prejudice experienced by construction
workers in a metropolitan region of Brazil observed
a high prevalence of aggressive, depressive and unhealthy behaviors, such as drug use. Such behavior
was associated to the experience of rejection within
the context of social discrimination.(9) These findings indicate that construction workers should be
the subjects of drug use prevention programs.
472
Acta Paul Enferm. 2014; 27(5):471-8
In the effort of detecting the level of risk related to drug use among male construction workers,
this study aimed at establishing the sociodemographic profile of workers at a construction company in a municipality of the state of Paraná, Brazil. It also aimed at identifying the risk related to
such drug use, as well as verifying the association
between the risk related to drug use and sociodemographic variables.
Methods
A cross-sectional study was carried out in 15 work
sites of a construction company in the municipality
of Maringá in Paraná, a state in the south of Brazil.
This municipality is located 426 km away from the
state capital, and had an estimated 385 thousand
inhabitants in 2013.(10) Maringá is a medium-sized
city with great agricultural production and a developing industrial area (although there are some large
industries) and well-developed service and commerce sectors.
The sample comprised 446 men who worked
for a construction company and who were directly
involved with building construction. Workers were
divided into two professional categories: semi-official, better known as laborers, and official, represented by masons, carpenters, reinforcing iron
and rebar workers, painters, electricians, finishing
workers, and others. Criteria for inclusion were:
male workers with a formal work contract, 18 years
or older; criteria for exclusion were: absenteeism,
refusal to participate in the study, and those who
worked on the higher strata of the building, which
could pose danger to the researcher and the worker.
Upon receiving the construction company’s
permission to conduct the study, the researcher
was taken to the work sites and introduced to the
workers, who were instructed as to the objectives
of the study. Once the participants signed the free
and informed consent form, the interviews were
conducted, which took place between March and
June 2012. Interviews were divided into two sections: worker sociodemographic information and
the Alcohol, Smoking and Substance Involvement
Gavioli A, Mathias TA, Rossi RM, Oliveira ML
Screening Test (ASSIST), by the World Health Organization (WHO).
The following sociodemographic variables were
used: age, education level, marital status, skin color,
municipality of residence, wages, living conditions,
children, time of service in construction, family income, professional category and absenteeism related to drug use.
The ASSIST-WHO instrument was translated
and validated in Brazil and consists of eight questions about the use of nine classes of abuse drugs (tobacco, alcohol, cannabis, cocaine, amphetamines,
sedatives, inhalants, hallucinogens and opioids). Its
questions assess the frequency of use for each abuse
drug (in lifetime and in the last 3 months) through
the following variables: problems related to drug
use; concern of people close to the user; interference
with role responsibility; failed attempts to quit or
cut down drug use; compulsion to use; and injecting drug use. Each answer corresponds to a score
ranging from zero to 8, and the total sum can vary
from zero to 39.(11,12)
In terms of defining the risk related to alcohol
use, a score from zero to 10 on the test is considered
lower risk; from 11 to 26 moderate risk; and when
higher than 27 points, it represents high risk up to
the progression of dependence. For the other abuse
drugs, the scores required for each category are: 0-3
points; 4-26 points and higher than 27 points, respectively. Thus, a range of problems associated to
substance use can be identified, which include acute
intoxication, regular use or dependence and high
risk of injecting behavior. Scores falling within the
intermediate range of the ASSIST indicate the use
of hazardous or harmful substances (moderate risk)
and the highest scores indicate substance dependence (high risk).(11,12)
The data collected were compiled using the
IBM Statistical Package for the Social Science
(SPSS®) software, and the independent variables
were dichotomized so that a descriptive statistical
analysis and multinominal logistic regression could
then be conducted. The objective of this method
was to investigate the variables associated to the results (dependent variable: level of risk provided by
the ASSIST score, classified as lower, moderate and
high, for tobacco, alcohol and illicit drugs). To this
end, lower risk was established as the baseline of the
dependent variable and backward stepwise regression was used, with a 95% significance level. For the
significant variables in the final model, odds ratio
and its respective confidence intervals were adopted
as a measure of association.(13)
The development of this study complied with ethical guidelines for research involving human beings.
Results
A total of 418 workers who met the inclusion criteria were interviewed. Twenty-eight workers left the
study due to absenteeism (13 workers), leave of absence due to work accidents (5 workers), refusal to
participate (4 workers) and due to an inaccessible/
hazardous workplace (6 workers).
The mean age of the sample was 41.1 (±12.6)
years, being that the youngest was 18 and the oldest, 74. Most workers (64.5%) were in the 36 to
74 year age group. When separated by professional
category, the mean age of official workers was 43.1
(±11.3) years and the mode, 52 years. The mean age
of semi-official workers was 38.3 (±13.6) years and
the mode, 23 years.
As observed, 73.7% of workers had up to 8
years of schooling (elementary school), 78.9% were
married or lived with a partner, 54.5% were white,
96.6 were catholic and 50.2% from municipalities neighboring Maringá. Most earned less than
three minimum monthly wages, were home owners
(58.4%), had children 79.2%, had over 10 years of
experience with construction work (79.2%), with
a family income lower than R$2,400.00/month
(67.7%) and were official construction workers
(65.1%). Semi-official workers (laborers) represented 34.9% of our sample. When asked if they had
missed work due to hangovers after a period of drug
abuse, 76.3% replied affirmatively (Table 1).
The prevalence of drug use in lifetime was 91%
for alcohol, 72.4% for tobacco, 18.2% for cannabis and 6.7% for cocaine. Inhalant drugs, especially solvents, were mentioned by 5.2% of the interviewed workers. Other drugs were used by 1.5% of
Acta Paul Enferm. 2014; 27(5):471-8
473
Risks related to drug use among male construction workers
workers, and 5.4% reported never having used or
experimented with any drug of abuse.
Table 1. Construction workers according to sociodemographic
variables
Variables
n(%)
Age
18-35
148(35.4)
36-75
270(64.6)
Years of schooling
Up to 8 years
308(73.7)
More than 8 years
110(26.3)
Marital status
With partner
330(78.9)
Without partner
88(21.1)
Skin Color
White
228(54.5)
Not white
190(45.5)
Religion
Has a religion
No religion
404(96.6)
workers, of which 2.6% presented moderate risk and
2.4%, high risk. Furthermore, the prevalence of risk
associated to the use of cocaine was identified among
1.7% of workers, of which 1.2% presented moderate
risk and 0.5% with high risk (Table 2).
Table 2. Construction workers according to classification of risk
related to drug use
Drug of abuse*
Tobacco
Alcohol
Cannabis
Cocaine
14(3.4)
Residency
n (%)
Lower
258(61.8)
Moderate
136(32.5)
High
24(5.7)
Lower
277(66.3)
Moderate
112(26.8)
High
29(6.9)
Lower
397(95.0)
Moderate
11(2.6)
High
10(2.4)
Lower
411(98.3)
Moderate
5(1.2)
High
2(0.5)
Other municipalities
210(50.2)
*More than one answer possible
Maringá
208(49.8)
Multinominal logistic regression analysis of moderate and high risk with respect to the worker’s sociodemographic variables demonstrated a significantly higher chance of risk related to (in the moderate and high
levels) the use of tobacco among workers who reported
episodes of absenteeism, not being home owners and
belonging to the semi-official category. On the other
hand, having less than 10 years of experience with construction work represented a protective factor for the
risk related to tobacco use at the moderate and high
level. An association was found between belonging to
the 36 to 74 age group and moderate level of risk. On
one hand, it represents a protective factor for the moderate risk level, and on the other it is associated to increased chances of elevated risk levels (Table 3).
Regarding the risk related to alcohol use, a
significant association was also observed between
moderate and high risk with work absenteeism, not
owning residency and having less than 8 years of
schooling (Table 3).
The low number of construction workers who reported the use of illicit drugs found in this study could
have influenced the statistical analysis. Thus, the use of
cannabis and cocaine were grouped into one category
(illicit drugs). Factors associated with higher chances
of moderate and high risk related to the use of illicit
drugs were absenteeism and belonging to the semi-official professional category (Table 3).
Wages
More than 3 minimum monthly wages*
332(79.4)
More than 3 minimum monthly wages
86(20.6)
Living conditions
Home owner
244(58.4)
Not home owner
174(41.6)
Children
With children
331(79.2)
No children
87(20.8)
Time of service
More than 10 years
239(57.2)
Less than 10 years
179(42.8)
Family income
Less than R$ 2.400,00/month
283(67.7)
More than R$ 2.400,00/month
135(32.3)
Professional category
Oficial
272(65.1)
Semi-official
146(34.9)
Absenteeism due to drug use
Yes
319(76.3)
No
99(23.7)
* The minimum monthly wage in 2012 was R$ 622.00
The data relative to the prevalence of risk associated
to drugs of abuse, as classified by the ASSIST-WHO,
are presented as follows. When considering tobacco
use, 38.2% of workers were classified as presenting risk
for health problems due to substance use, of which
32.5% presented moderate risk and 5.7%, high risk.
When considering alcohol use, 33.7% of workers had
related risks, of which 26.8% were moderate, and 6.9%
were high. With respect to illicit drugs, we identified
a prevalence of risk associated to cannabis in 5.0% of
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Related risk
Acta Paul Enferm. 2014; 27(5):471-8
Gavioli A, Mathias TA, Rossi RM, Oliveira ML
Table 3. Results of the multinomial logistic regression analysis for the effect of the selected variables on the levels of risk related to
drug use
Drug of abuse
Tobacco
Variable
Category
Absenteeism
Moderate Risk
High Risk
OR
CI95%
OR
CI95%
Yes
1.8
1.1-3.1
15.1
5.2-43
Residence
No owned
2.4
1.5-4.0
1.8
1.0-4.2
Professional category
Semi-official
1.7
1.1-2.8
1.7
1.1-2.5
Time in profession
<10 years
0.3
0.1-0.7
0.2
0.0-0.9
Age (years)
36 to 74
0.4
0.2-0.8
2.3
1.3-17.9
Absenteeism
Yes
3.9
2.1-7.2
30
10-95
Residence
No owned
1.8
1.1-3.3
4.3
1.5-12.3
Alcohol
Schooling
<8 years
2.1
1.2-3.7
1.0
0.3-2.4
Absenteeism
Yes
4.3
1.2-14.8
4.1
1.1-16.1
Professional category
Semi-official
2.0
0.5-7.2
5.1
1.1-23.6
Illicit drugs
OR – odds ratio; IC95% – confidence interval of 95%
Discussion
The limitation of this study regards the use of data collected in a less than ideal situation, i.e., at work. This
situation could have resulted in lack of sincerity, for
the theme touches on illegality, and this could have led
to an underestimation of data. On the other hand, this
method does have its advantages, for the use of standardized instruments helps professionals to establish
the limits for defining harmful drug use.
Few Brazilian studies have focused on monitoring the risk related to drug use among workers. Most of them discuss instrument validation, for this technology has only recently been
disseminated. Most studies used the CAGE
test (an acronym regarding its four questions Cut down, Annoyed by criticism, Guilty and
Eye-opener) and the AUDIT, the Alcohol Use
Disorders Identification Test, which only investigates alcohol use and dependence.(1) This limits
the comparability of prevalence of risk related to
drug use in general and among men, particularly
construction workers. For this reason, the findings of the present study were compared with
national population-based surveys to investigate
the risk levels related to other drugs of abuse.
The present study found a high prevalence
of lifetime use of tobacco, alcohol, cannabis and
cocaine. When comparing the data of our study
to that of a household survey on the use of psychotropic drugs conducted in 2006, involving
the 108 largest cities in Brazil, the prevalence of
lifetime use of alcohol, tobacco, cannabis and
cocaine, for men in the South region was 81.7,
56.9, 15.7 and 5.4%, respectively.(14)
Another national survey conducted in 2012
found a prevalence of lifetime use of 7% for
cannabis and 4% for cocaine.(15) Our findings
demonstrate that the lifetime prevalence was
greater among construction workers, with the
exception of inhalant drugs, which presented
similar values. This higher prevalence may be
significantly related to the prevalence of regular use, which can progress to continued and
long-lasting use. However, the course of evolution followed in experiences with drugs is unknown, indicating that active prevention when
drug use is initiated may be the only effective
means of prevention.(16)
In the present study, alcohol and tobacco were
confirmed as the main legal abuse-causing substances; cannabis and cocaine were the main illicit
abuse-causing substances. Regarding the prevalence
of high levels of risk related to tobacco use, which
indicate dependence, although there was an expressive prevalence among workers, it was still lower
than the levels found in national surveys. Such surveys observed a prevalence of 12.2% among men in
the South region of Brazil(14) and 16.9% in Brazil in
general.(15) However, taking into consideration individuals with moderate and high levels of risk, which
indicate harmful and continued use, the workers in
our study presented an expressively higher number
than those found in the national surveys, reaching
values two to three times higher.
Regarding the prevalence of levels of risk related to the use of alcohol, a lower number of
Acta Paul Enferm. 2014; 27(5):471-8
475
Risks related to drug use among male construction workers
workers fulfilled the criteria for dependence
(high risk level). The survey for the South region of Brazil found 14.9% of male individuals
to be dependent.(14) On the other hand, the latest
national survey in 2012 showed that 10.5% of
individuals of the general population were dependent.(15) However, if we calculate the number
of individuals included in the intermediate range
of risk (moderate level), we observe that the construction workers present a higher prevalence of
harmful and continued alcohol use, reaching two
to three times higher values than those found in
the national surveys.
With respect to cannabis, the prevalence of
high risk (an indicator of dependence) observed
was greater than that found among men in the
South region of Brazil in 2006, which was 1.1%.
(14)
However, this prevalence was lower than that
observed in the latest survey of 2012, with 4.4%
of male individuals.(15) If we add to this number
individuals who score in the intermediate ranges (moderate risk), we observe that, among construction workers, the frequent and continued
use of cannabis can be considered higher than
that observed in the general population in the
surveys mentioned above.
The last national survey on drug use indicated a 2% prevalence of cocaine dependence
among the Brazilian population.(15) Among the
construction workers, there was a prevalence of
individuals with high risk (dependence indicator) related to the use of this substance lower
than that of the general population. However,
if we add to this number those individuals who
fulfill the criteria for moderate levels of risk
(with frequent and continued use), we observe
that workers presented a prevalence similar to
that found in the national survey.
In another study on the prevalence of drug
use among public construction workers of the
state of Minas Gerais,(17) there were similarities
regarding which were the most used drugs, as
well as the high level of use in lifetime. However,
the authors did not stratify the data according
to risks related to drug use, only according to
the frequency of use. Nonetheless, an interesting
476
Acta Paul Enferm. 2014; 27(5):471-8
piece of information was the number of individuals who were classified as needing to be referred to intensive treatment, which were 7.5%,
21.5%, 3% and 2.5%, respectively, for the use
of tobacco, alcohol, cannabis and cocaine. When
comparing the data, we observe that the workers
in our study presented a lower prevalence of continued drug use.
The association between absenteeism and
drug use, as was observed in this study, has already been investigated by other studies. Individuals who frequently use alcohol tend to be
more absent at work, since such use can result
in “hangovers,” leading to the absence of partial
or full days of work. Moderate and high levels of
risk were associated to more days absent due to
medical consultations or sick leaves.(18) Absenteeism causes direct effects that are not only felt by
employers, but also by other workers who need
to take on additional tasks in order to compensate for their absent coworkers. This increased
workload harms and overloads these workers.(19)
The sociodemographic characteristics of the
participants of this study portray the reality of
construction workers in Brazil.(5,17) These characteristics include, for example, low education and
socioeconomic levels, which in this study were
associated to moderate and high risk of tobacco,
alcohol and illicit drug use. These characteristics
can lead to factors that predispose the individual
to a higher risk of involvement and drug use.(2,9)
We also found an association between the use
of tobacco and illicit drugs with the semi-official
category, consisting of younger workers who are
still learning their trade. With regards to the use
of alcohol and illicit drugs, other studies have
shown that younger people tend to drink alcohol
in higher levels or with greater risk, and that this
group is considered as being at the highest risk
for health problems due to alcohol, tobacco and
illicit drugs. Thus, the prevalence of use patterns
among this demographic segment should be especially monitored.(19,20)
An important factor regarding drug use
among construction workers is that work sites
consist primarily of men, for the work activities
Gavioli A, Mathias TA, Rossi RM, Oliveira ML
require conditions considered to be masculine,
such as physical strength. We present the hypothesis that men are more solicited for this type of
work activity because they are more prone to adventure and risk-taking. Our results corroborate
that of other studies that have shown a greater
prevalence of drug use and dependence among
men. Historically, drug use is a profile associated to the male population, for it is a manner of
establishing and maintaining bonds with other
men of the same social status.(17,20)
A study conducted in Maringá analyzing the
profile of hospital morbidity, found the 56.1%
of total hospitalizations consisted of men, primarily young and adults, between the ages of 20
and 59. This study found that mental disorders,
21.5% and injuries and intoxication, 25.1%
were the main diagnoses for hospitalized men
from Maringá in the three year period from 2009
to 2011.(21) These findings are in agreement with
the conclusion of the present study that the male
population is more vulnerable to some types of
mental disorders, which include drug abuse diagnoses and externally caused lesions, frequently
related to drug use.
The fact that an expressive number of interviewed workers presented high use in lifetime,
continued use and moderate and high risk levels of drug use emphasizes how vulnerable this
professional category is to drug use. Such use is
considered by the WHO as the main preventable
cause of death and years of potential life lost.
(22)
In this sense, an instrument such as the ASSIST-WHO, which allows for screening the risk
related to drug use, easy to apply and interpret,
and that allows for brief interventions and result
feedback, is an important option for the prevention and early detection of drug use among construction workers.(23)
In light of the results of the present study, we
observe the importance of this type of screening with standardized instruments by healthcare,
nursing, worker’s health and primary care teams.
This technology can be very useful in the detection, early intervention and, consequently,
prevention of this type of drug use among work-
ers, for one of the greatest difficulties found by
health professionals regarding drug use in the
community consists in determining the limits
which define drug abuse.(1,11)
The results of this study can also help construction companies that wish to implement
prevention programs that assess the impact of
measures for controlling drug use. In the nursing
field, this study indicates the need for the team
to consider the working environment as a whole,
not only focused on the classic occupational hazards or on the treatment of drug users. Nursing
professionals must also consider the male population in the work place and their actions, which
will help reduce drug use and increase safety and
health, not only with regards to construction
work, but also in the most diverse occupational
realities. It is necessary for the nursing professional to be aware of the morbidity profile of the
male population, in order to raise more awareness among adult men about the benefits of acting towards disease prevention.(21,24)
Conclusion
Tobacco and alcohol were the main drugs used
among workers. The level of risk related to the use
of tobacco, alcohol, cannabis and cocaine was high
when compared to those of the general population.
Acknowledgements
The authors thank the workers and the Construction
Worker Labor Union of Maringá, SINTRACON,
and the staff of the Committee for Incentive of Formality in Civil Construction, especially Ms. Mary
and all of the construction workers.
Collaborations
Gavioli A contributed with the project conception,
development of the research and drafting of the
article. Rossi RM collaborated with the sampling
plan, statistical analysis and data interpretation.
Mathias TAF and Oliveira MLF contributed with
the critical review of its intellectual content and the
final approval of the version to be published.
Acta Paul Enferm. 2014; 27(5):471-8
477
Risks related to drug use among male construction workers
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social na construção civil. Interface - Comunicação, Saúde, Educação.
2010; 4(32):233.
6. Araujo JS, Silva SE, Conceição VM, Santana ME, Souza RF. A bebida
alcoólica no contexto laboral: um diálogo mediado pelas representações
sociais. Tempus Actas de Saúde Coletiva. 2012; 6(3):217-33.
7. Scussiato LA, Sarquis LM, Kirchhof AL, Kalinke LP. [ Epidemiological
profile of serious accidents at work in the State of Paraná, Brazil, 20072010]. Epidemiol Serv Saúde. 2013; 22(4):621-30. Portuguese.
8. Iriart JA, Oliveira RP, Xavier SS, Costa AM, Araújo GR, Santana VS.
Representações do trabalho informal e dos riscos à saúde entre
trabalhadoras domésticas e trabalhadores da construção civil. Ciênc
Saúde Coletiva. 2008;13(1):165-74.
9. Borges LO, Peixoto TP. Ser operário da construção civil é viver a
discriminação social. Rev Psicol Organ Trab. 2011; 11(1):21-36.
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[Internet]. Brasília, DF: IBGE Cidades, Maringá; 2013 [citado 2014
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[Validation of the Brazilian version of Alcohol, Smoking and Substance
Involvement Screening Test (ASSIST).] Rev Assoc Med Bras. 2004;
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13.Agresti A. An introduction to categorical data analysis. 3rd ed. New
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Paulo, SP: UNIFESP; 2006.
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[Internet]. São Paulo: INPAD; 2013[citado 2014 Mai 2]. Disponível em:
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Original Article
The effect of Reiki on blood hypertension
Efeito do Reiki na hipertensão arterial
Léia Fortes Salles1
Luciana Vannucci2
Amanda Salles3
Maria Júlia Paes da Silva1
Keywords
Hypertension; Therapeutic touch;
Complementary therapies; Mind-body
therapies; Integrative medicine
Descritores
Hipertensão; Toque terapêutico;
Terapias complementares; Terapias
mente-corpo; Medicina integrativa
Submitted
May 9, 2014
Accepted
June 23, 2014
Corresponding author
Léia Fortes Salles
Doutor Enéas de Carvalho Aguiar
Avenue, São Paulo, SP, Brazil.
Zip Code: 05403-000.
[email protected]
Abstract
Objective: Determining the immediate effect of Reiki on abnormal blood pressure.
Methods: An experimental, double-blind study, in which were included 66 hypertensive patients, randomized
to the three following study groups: control, placebo and experimental. The intervention lasted 20 minutes, the
control group remained at rest, the placebo group received an imitation of the studied technique (mock Reiki)
and the experimental group received the Reiki technique. Blood pressure was measured before and after the
intervention by the same person with the same instrument.
Results: There was a decrease in blood pressure in the three groups and the reduction was greater in the
experimental group, followed by the placebo and the control group. The ANOVA model for repeated measures
showed a statistically significant difference among the groups (p <0.0001).
Conclusion: Reiki had a positive effect on reducing abnormal blood pressure, suggesting to be a complementary
technique for the control of hypertension.
Resumo
Objetivo: Verificar o efeito imediato do Reiki na pressão arterial alterada.
Métodos: Pesquisa experimental, duplo cego no qual foram incluídos 66 hipertensos, randomizados para
três grupos de estudo: controle, placebo e experimental. A intervenção teve duração de 20 minutos, o grupo
controle permaneceu em repouso, o grupo placebo recebeu uma imitação da técnica estudada e o grupo
experimental recebeu a técnica de Reiki. A pressão arterial foi aferida antes e depois da intervenção pela
mesma pessoa e como mesmo aparelho.
Resultados: Houve diminuição da pressão arterial nos três grupos e a redução maior foi no grupo experimental,
seguido pelo grupos placebo e controle. O modelo ANOVA, para medidas repetidas mostrou que houve
diferença estatísticamente significativa entre os grupos (p<0,0001).
Conclusão: O Reiki teve efeito positivo na diminuição da pressão arterial, sugerindo ser uma técnica
complementar para o controle da hipertensão.
Universal Trial Number: U1111-1152-4520
Registro Brasileiro de Ensaios Clínicos: REQ 2270
Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, Brazil.
Vigilância em Saúde, Prefeitura de São Paulo, São Paulo, SP, Brazil.
3
Fundação Getúlio Vargas, São Paulo, SP, Brazil.
Conflicts of interest: no conflicts of interest to declare.
1
DOI
http://dx.doi.org/10.1590/19820194201400078
2
Acta Paul Enferm. 2014; 27(5):479-84
479
The effect of Reiki on blood hypertension
Introduction
Due to the rapid aging of the world population,
the profile of mortality started to be characterized
by complex and costly diseases, common to the advanced age and represented mainly by chronic degenerative diseases.(1) Among them, cardiovascular
diseases are a major public health problem throughout the world and, in recent decades, according
to official records, the first cause of death in many
countries.(1)
The increase in chronic diseases leads to a new
global health challenge, which is finding new and
more effective ways to prevent the onset of these
diseases and its disabilities.
Complementary therapies with its holistic dimension can be useful tools for coping with this
challenge, to the extent that they assists in maintaining homeostasis throughout life.
The abnormal blood pressure is the most
common sign of hypertension that is recognized
as the main risk factor for cardiovascular morbidity and mortality. The main cause of mortality
in Brazil and worldwide is found in the group of
cardiovascular diseases.
Hypertension affects more than a billion people worldwide and the prognostics indicate that by
2025 the number of people with this problem may
increase by 29%.(2) In Brazil, it is a highly prevalent
disease, with rates ranging from 22% to 44%.(2)
There are several risk factors that contribute to
hypertension, the main ones being obesity, alcohol
consumption, sedentary lifestyle and smoking.(3)
Habits, lifestyle and adherence to treatment have
strong influence in disease control.(3-5)
The harmony, quantity and balance of Vital
Energy in the body are essential for the health and
proper functioning of the being. At birth we have
a certain level of this energy, however, at spending various amounts of it day-to-day without having a satisfactory recovery, one will probably face
physical, emotional and mental imbalances, and/
or diseases.
Reiki that means universal vital energy, is a Japanese technique that aims to assist in restoring the
energetic system of the body, by stimulating the
480
Acta Paul Enferm. 2014; 27(5):479-84
natural healing processes of the body.These processes can be used to induce relaxation and treat health
problems. Reiki practitioners use the approach by
slight hand contact to facilitate the opening of their
own energy channels and those of the patients.(6)
Reiki stimulates the body to balance itself, primarily by stimulating the immune system, predisposing it to an own re-establishment according to
one’s personal state. Beyond the physical aspect, the
vital energy acts on psychological and emotional
aspects, improving the willpower to change habits
that are often deleterious to health, such as smoking, inappropriate feeding patterns and maintaining depressive thoughts and behaviors.
The nursing care aims at a comprehensive customer care, and by using Reiki, the nurses expand
the possibilities of care in a simple, safe and noninvasive way.
The Nursing Council was the first council
among health professions to approve and recognize the use of complementary therapies when
establishing and recognizing Alternative Therapies as a specialty and/or qualification of nursing
professionals.(7)
Among the Nursing diagnoses proposed by the
NANDA that justify the application of Reiki, there
are the following diagnoses: Energy field disturbance; Insomnia; Sleep deprivation; Fatigue; Anxiety; Stress overload and Acute and chronic pain.
In several studies carried out by nurses, the decrease of migraine, pain, fatigue, anxiety, nausea and
vomiting were found as results of the application of
Reiki, as well as the increase in relaxation and accelerated cicatrization as possible benefits, besides the
increase in willingness to modify unhealthy habits
and styles of life.(7,8) It is known that healthy habits
help in controlling and maintaining the blood pressure at adequate levels.
There are few studies using complementary
techniques for reduction of cardiovascular risk factors. A case study describes the reduction of blood
pressure with techniques of the Traditional Chinese
Medicine, specifically acupuncture, Tai Chi and Chi
Kung.(9) The few randomized and controlled studies
with energy techniques like Meditation, Therapeutic Touch, Pranic Healing and Reiki suggest that
Salles LF, Vannucci L, Salles A, Silva MJ
they reduce anxiety and stress, factors that contribute to the imbalance of blood pressure.(10)
A study conducted in the laboratory with
stressed rats showed a greater and statistically significant reduction in frequency of heart rates with the
application of Reiki, in comparison with an intervention imitating the technique (placebo). None of
the interventions affected the blood pressure. The
study authors conclude that Reiki favors homeostasis and reduces the activity of the sympathetic nervous system.(11)
Another study demonstrates that Reiki has been
effective in decreasing the heart rate in myocardial
post-infarction patients, suggesting the vagal action
of the technique.(12)
A randomized double-blind study of patients
with burnout syndrome concludes that the application of Reiki decreases the levels of IgA (immunoglobulin A) and diastolic blood pressure, and also,
that there is a statistically significant correlation between the intervention duration and the decrease of
blood pressure.(6)
A systematic review on the therapeutic effect of
Reiki concluded that there is still no way to evaluate the effectiveness of therapy and that further research with appropriate methodologic designs are
necessary.(13)
With the increasing use of integrative practices
worldwide, further research in this area is necessary
in order that such practices can be safely and effectively followed. Therefore, the aim of the present
study was observing the immediate effect of Reiki
on abnormal blood pressure.
Methods
This is a randomized, cross-sectional, descriptive
and double-blind clinical trial, in which nor the
participants and neither the person checking the
blood pressure have knowledge of who belongs to
each group.
The survey was carried out in a health institution in the city of São Paulo, southeastern region
of Brazil. In total, 170 hypertensive patients were
included in the study. Using 80% confidence in-
terval and 5% error was reached a sample size of
66 patients, who were divided into three groups:
control, placebo and experimental.
The inclusion criterion was blood pressure at or
above 140x90 mmHg on the day of survey. The exclusion criteria were: being under 18 years old and
the presence of symptoms consistent with hypertensive emergency, regardless of the pressure level.
After the medical consultation, patients referred
by the clinic and who had blood pressure greater
than or equal to 140x90 mmHg were invited to
participate in the study. The volunteers were randomized and formed three groups: experimental,
placebo and control.
Randomization was performed using sealed
and shuffled envelopes containing one of the three
groups, which were distributed and open at the moment each patient was admitted in the study.
The experimental group received Reiki. The
placebo group received a ‘mock Reiki’ applied by
someone without training in Reiki, but previously trained and following the established protocol
in points of the body that were not energy centers
or meridians, in random order and intercalated
with periods without movements. The control
group remained only at rest. The intervention
lasted 20 minutes in all groups and the blood
pressure was measured immediately before and
after the intervention, by the same person and
with the same instrument.
Although blood pressure had already been
checked by the clinic physician, it was measured
again, in order that both measurements (before and
after the intervention) were performed under the
same conditions: same instrument, professional and
place, with prior rest of 15 minutes. All results were
recorded in the clinical record.
At the end of the experiment, the subjects of the
placebo and control groups were invited to experience the actual reiki technique, according to availability of dates and times.
Data were analyzed by number and percentage.
The Chi-squared and ANOVA tests were used for
statistical treatment to verify the homogeneity between the groups. The ANOVA model was used to
analyze the effect of the intervention in the three
Acta Paul Enferm. 2014; 27(5):479-84
481
The effect of Reiki on blood hypertension
groups (treatment p-value) and whether there was
difference in outcomes among the groups (interaction p-value).
The development of study followed the national
and international standards of ethics in research involving human beings.
Results
Sixty-six subjects who met the inclusion criteria were enrolled in the study: 22 in the control
group, 22 in the placebo group and 22 in the experimental group.
The Chi-squared and ANOVA tests showed
that the groups were homogeneous in relation to
variables such as gender and age.
The maximum and mean initial values of blood
pressure were higher in the Reiki group (mean of
161.0 and 128.4, respectively) and the initial minimum blood pressure value was higher in the con-
trol group (mean of 97.3). The statistical test choice
took these differences into account.
The volunteers have lived with hypertension for
12 years on average, and although their blood pressure values were equal to or above 140 x 90 mmHg,
almost all reported following the recommended
diet and using the prescribed medication.
The majority of the sample was comprised of
female volunteers (66.6%) with a mean age of
60 years.
The result showed a reduction in blood pressure
in all three groups (treatment p-value <0.001), but
it was more pronounced in the experimental group.
A statistically significant difference was also demonstrated among groups, highlighting the experimental group result (interaction p-value <0.001), as
shown in table 1.
The reduction in blood pressure was greater
in the experimental group, followed by the placebo group and the control group, as shown in
table 2.
Table 1. Comparison of maximum, minimum and mean blood pressure (BP) values in the three groups by the ANOVA model
Pre-treatment
Post-treatment
Mean (SD)
Mean (SD)
Treatment
Interaction
Reiki
161.00(19.03)
147.36(19.4)
< 0.001
0.004
Placebo
151.23(9.27)
146.82(11.71)
Control
154.05(13.19)
150.50(15.79)
Reiki
95.91(6.55)
88.18(10.53)
< 0.001
0.006
Placebo
91.82(5.68)
90.00(6.36)
< 0.001
0.001
Variable
Group
Maximum BP
Minimum BP
Mean BP
Control
97.27(8.41)
95.23(10.17)
Reiki
128.45(10.75)
117.77(12.72)
Placebo
121.52(5.44)
118.41(7.96)
Control
125.66(9.61)
122.86(11.78)
p-value*
*ANOVA for repeated measures
Table 2. Maximum, minimum and mean blood pressure (BP) values before and after the intervention in the three groups
482
Maximum BP before
Maximum BP after
Difference
Reiki
161.0
147.4
13.6
Placebo
151.2
146.8
4.4
Control
154.0
150.5
3.5
Maximum BP before
Maximum BP after
Difference
Reiki
95.9
88.2
7.7
Placebo
91.8
90.0
1.8
Control
97.3
95.2
2.1
Maximum BP before
Maximum BP after
Difference
Reiki
128.4
117.8
10.6
Placebo
121.5
118.4
3.1
Control
125.6
122.8
2.8
Acta Paul Enferm. 2014; 27(5):479-84
Salles LF, Vannucci L, Salles A, Silva MJ
Discussion
The sample size may have not described the effect
of all the involved variables, which was considered a
limitation of the study results. However, the result
contributes to analyze the effect of complementary
therapies on episodes of arterial hypertension.
The average age of volunteers is within the age
group described in the literature of patients with
hypertension.(2) Usually, women are the ones that
most seek medical attention, but as both genders
are affected by hypertension, it is not surprising
that in this study there was a large presence of
men, corresponding to approximately 36.4% of
the sample.(2)
A decrease in blood pressure was expected in
the three groups, with different gradations between
the greater and the smaller reduction for the experimental, placebo and control groups, respectively.
The control group rested for 20 minutes, and it
is known that resting may help in lowering blood
pressure. The placebo group received a mock Reiki
and although the person responsible for the intervention was not initiated in the Reiki technique,
she emits energy, as all living beings do. Finally, the
experimental group received the Reiki technique,
which resulted in greater decrease in blood pressure
as expected in the hypothesis, corroborating the
earlier presented study.(6)
The reduction in blood pressure can result from
the energy balance of the body and the vagal action
of the technique that facilitates homeostasis, which
is an assumption shared by other authors.(6,12)
The intervention time was set as 20 minutes,
because it is known that the lack of time is a factor
that causes people not to participate in researches.
And although in one of the studied articles(13) the
intervention duration had a statistically significant
correlation with the decrease in blood pressure, we
observed reduction even with the 20 minutes established in the present study.
Forming a placebo group to increase the scientific evidence of the study results was not an easy
task. We all have energy that is in constant interaction with the environment and surrounding people.
Thus, it takes a lot of awareness and self-knowledge
to avoid this energy from suffering influence from
the environment and direct it in situations where
others are in need of energy, which is a frequent fact
in health institutions.
Patients who had not received the Reiki technique were invited to return and try it. On this occasion, the initial and final blood pressure was also
measured, and the fact that in most people the initial blood pressure was lower than at the time of the
study (when volunteers had a medical consultation)
called the attention. This reinforces the concept of
the white coat syndrome.(14)
Randomized and double-blind studies with
energy and integrative practices that concomitantly take care of emotional dimensions step
into a recent paradigm in the line of research
based on evidence.
More research is needed, both to strengthen the results of this investigation, as to expand
knowledge and clarify other points, like the minimum time needed to benefit from the technique
and the lasting of results.
Conclusion
Reiki had a positive effect on the reduction of abnormal blood pressure, suggesting to be a complementary technique for the control of hypertension.
Acknowledgements
Thanks to Carmem Luisa Pelosini Mazelli for the
collaboration and management, to the staff of the
institute where data collection was carried out, and
to the statistician Bernardo dos Santos for performing the data analysis.
Collaborations
Salles LF and Vannucci L contributed to the
project design, implementation research, discussion of the data and drafting and revision of the
article. Silva MJPS collaborated with the project
design, data discussion, drafting and revision of
the article and Salles A with implementation of
the research, discussion of the data and writing
the article.
Acta Paul Enferm. 2014; 27(5):479-84
483
The effect of Reiki on blood hypertension
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2. Sociedade Brasileira de Hipertensão; Sociedade Brasileira de
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9. Cormack BA. A multifaceted integrative approach to heart, weigh, and
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Rev Latinoam Enferm. 2009; 17(4):462-467. Portuguese.
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12. Friedman RSC, Burg MM, Miles P, Lee F, Lampert R. Effects Reiki on
autonomic activity early after acute coronary syndrome. J Am Coll
Cardiol. 2010; 56(12):995-6.
6. Rodriguez LD, Morales MA, Villanueva IC, Lao CF, Polley M, Fernandez
de la Penas C. [The application of Reiki in nurses diagnosed with
Burnout Syndrome has beneficial effects on concentration of salivary
IgA and blood pressure]. Rev Latinoam Enferm. 2011; 19(5):1132-8.
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13.VanderVaart S, Gijsen VM, Wildt SN, Koren G. A systematic review
of the therapeutic effects of Reiki. J Altern Complement Med. 2009;
15(11):1157-69.
7. Conselho Federal de Enfermagem. Resolução COFEN 197. [Internet].
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14.[First Brazilian position on resistant hypertension. Hypertension
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Original Article
Craniocerebral trauma in motorcyclists:
relation of helmet use and trauma severity
Traumatismos craniocerebrais em motociclistas:
relação do uso do capacete e gravidade
Viviane da Cunha Dutra1
Rita Catalina Aquino Caregnato1,2
Maria Renita Burg Figueiredo1
Daniela da Silva Schneider1
Keywords
Accidents, traffic; Emergency medical
services; Brain injuries; Motorcycle
Descritores
Acidentes de trânsito; Serviços
médicos de emergência; Traumatismos
craniocerebrais; Motocicletas
Submitted
July 3, 2014
Accepted
July 29, 2014
Abstract
Objective: Relating the helmet use with the severity of craniocerebral trauma in injured motorcyclists treated
at a trauma hospital.
Methods: A cross-sectional, retrospective study. The study population consisted of 188 records of service to
injured motorcyclists in a four-month period. The Glasgow Coma Scale was used to characterize the severity
of trauma.
Results: The profile is 84.6% of males and 55.3% aged between 18 and 29 years. Regarding the use of
helmet at the time of the accident, 51.6% used, 6.4% did not use, 17.6% used it inappropriately, and there
were no records in 24.5%. Among the 51.6% of motorcyclists who used the protective gear, 86.6% had
mild craniocerebral trauma, 12.4% had moderate, and 1% severe. The most serious injuries occurred in
motorcyclists in which there were no records on helmet use.
Conclusion: The motorcyclists who used the helmet, had mild craniocerebral trauma in 44.7% of cases,
moderate trauma in 6.4%, and severe trauma in 0.5%. Victims without records of the situation of helmet use
had severe trauma (p≤0.000).
Resumo
Corresponding author
Daniela da Silva Schneider
Farroupilha Avenue, 8001, Canoas, RS,
Brazil. Zip Code: 92425-900
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400079
Objetivo: Relacionar o uso do capacete à gravidade dos traumatismos crâniocerebrais em motociclistas
acidentados atendidos em hospital de trauma.
Métodos: Estudo transversal, retrospectivo. A população foi constituída de 188 registros de atendimento a
motociclistas acidentados no período de quatro meses. Para caracterizar a gravidade do trauma foi utilizada
a Escala de Coma de Glasgow.
Resultados: Perfil: 84,6% sexo masculino, sendo 55,3% entre 18 e 29 anos. Quanto ao uso de capacete
no momento do acidente: 51,6% usavam; 6,4% não usavam; 17,6% usaram inadequadamente; 24,5%
não ocorreram registros. Dos 51,6% de motociclistas que utilizavam o equipamento de proteção, 86,6%
apresentaram Traumatismos Craniocerebrais leve; 12,4% moderado; e 1% grave. Os traumatismos graves
ocorreram mais nos motociclistas em que não havia registro sobre o uso do capacete.
Conclusão: Os motociclistas que utilizaram o capacete apresentaram trauma crâniocerebral leve em 44,7%,
moderado em 6,4% e grave em 0,5%. As vítimas sem registro da situação do uso do capacete tiveram
traumatismos graves (p≤0,000).
Universidade Luterana do Brasil, Canoas, RS, Brazil.
Universidade Federal de Ciências da Saúde de Porto Alegre, RS, Brazil.
Conflicts of interest: no conflicts of interest to declare.
1
2
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Craniocerebral trauma in motorcyclists: relation of helmet use and trauma severity
Introduction
In recent years, the economic stability in Brazil enabled the growth of various sectors producing consumer goods, with a 250% increase in the automotive, motorcycle and truck market.(1) In this context
of expansion, the increase in the production of cars
and motorcycles is found not only in Brazil but
worldwide.(2-5)
The use of motorcycle as a means of transportation and labor is a phenomenon caused by the easiness in purchasing and maintaining it, combined
with its agility, what explains the growth of sales in
this market.(6) The increasing number of vehicles,
especially motorcycles, traveling in cities and highways of the country brought negative consequences,
as increased occurrences and a large number of accident victims.(2,7)
The Brazilian traffic is one of the most dangerous in the world, with an accident for every 410
vehicles in circulation, while in Sweden the ratio is
1/21,400 vehicles. These numbers reflect a problem
of serious consequences for society, considering the
morbidity, such as partial or total disability, in addition to result in high costs.(8) Traffic accidents cost
the public coffers around R$ 28 million per year,
not counting the indirect costs.(1,3)
Accidents that victimize motorcyclists are a
public health problem of great magnitude and transcendence, with strong impact on morbidity and
mortality of the population. On the set of injuries
from external causes, the craniocerebral trauma
stands out in terms of magnitude, especially as a
cause of death and disability particularly for productive young people.(2,9)
The initial evaluation of patients who are victims of craniocerebral trauma includes the Glasgow
Coma Scale, data related to the accident and computerized tomography. This scale determines the severity of craniocerebral trauma by quantifying the
neurologic findings that result from the score sum
of the eye opening assessment, verbal response and
motor response, evaluating the depth and clinical
duration of unconsciousness and coma.(10)
The use of safety equipment, especially the
helmet, is an important factor to alleviate the
486
Acta Paul Enferm. 2014; 27(5):485-91
implications resultant of a motorcycle accident,
which is observed when the victim receives
emergency care. Hence, the correct use of this
protection item is essential. The helmet aims to
cushion the shock from the impact.(11)
In a motorcycle collision, the riders are
thrown from the vehicle. The movement of their
heads forward is interrupted when hitting an
obstacle, but the brain continues until hitting
the inside of the skull and then bounces back,
reaching the opposite side, which may result in
a minor or fatal injury.(11) Motorcyclists who do
not wear helmets are at a much higher risk of
traumatic injuries in the head and brain, or a
combination of them. Helmets create an additional protective layer for the head by protecting users from some of the most severe forms of
traumatic brain injury.(11) Therefore, victims of
motorcycle accidents suffer fewer injuries with
the use of protective helmets, reducing the risk
of injuries in the head by two thirds, and by half
in the cervical spine.(3)
The leading cause of death among users of motorcycles and bicycles are injuries to the head and
neck. In European countries, head injuries contribute with roughly 75% of deaths among users of motorized two-wheelers; in some countries of low and
middle-income, it is estimated that head injuries
are responsible for 88% of deaths. Fractures of the
nose, jaw, sinking of the face and skull, and injuries
to the eye and dental arch are among the most common occurrences.(11)
Given this context, arose the interest in investigating the issue: Is the severity of craniocerebral
trauma related with the helmet use in motorcycle
accidents? In order to answer the question of research was defined the objective of correlating the
helmet use with the severity of craniocerebral trauma, by using the Glasgow Coma Scale in injured
motorcyclists treated at a trauma hospital.
Methods
This is a quantitative retrospective cross-sectional
study carried out in the emergency room of a trau-
Dutra VC, Caregnato RC, Figueiredo MR, Schneider DS
ma hospital located in Porto Alegre / RS, Brazil.
This institution is a reference in trauma in the north
region of the city, and part of the Unified Health
System (SUS - Sistema Único de Saúde).
The population consisted of records of patients victims of motorcycle accidents treated at
the hospital emergency room with a diagnosis of
craniocerebral trauma, between 01/10/2012 and
31/01/2013. The sample considered all the patients admitted in the emergency hospital during
the study period defined for the survey. Inclusion criteria were records of patients injured by
motorcycle with a medical diagnosis of craniocerebral trauma, regardless if there were records
on helmet use. In this service, an average of 200
victims of motorcycle accidents are assisted every
month, of which 25% have craniocerebral trauma. There was no need for sample size calculation, since all records of patients who entered the
hospital because of a motorcycle accident with
craniocerebral trauma in the study period were
selected (100%), resulting in 188 records. A
spreadsheet in Excel was elaborated as a tool for
data collection with the following variables: age,
gender, helmet use, severity of craniocerebral
trauma and position occupied in the vehicle.
The Statistical Package for the Social Sciences version 13.0 was used for analysis of the collected data. Data were analyzed using tables and
simple percentages. The Fisher’s exact test was
used for the verification of significant association between the variables. In the analysis of results, the maximum level of significance assumed
was 5% (p≤0.05).
The development of the study met national
and international standards of ethics in research
involving human beings.
Results
In relation to the profile of the sample, 84.6% of
the 188 patients were male, and 55.3% were aged
between 18 and 28 years.
Regarding the use of helmet, in 51.6% of the
sample there were records of helmet use; in 17.6%,
there were records of inappropriate use because the
equipment fell off at the time of the accident; and
in 6.4%, the helmet was not used. It is noteworthy
that in 24.5% of cases there was no record whether
the equipment was used or not.
The distribution of victims of motorcycle accidents with craniocerebral trauma in relation to helmet use and the variables age, gender, position of
the motorcyclist, site of trauma, and injury severity
are presented in table 1.
It is observed that the age group between 18 and
28 years accounted for most of the victims who lost
the equipment during the crash.
The 188 victims suffered 277 traumas to the
head region, corresponding to more than one
trauma per patient. They all had head trauma,
as well as trauma to the jaw, face and neck. Eye
and dental trauma also occurred, though less frequently. The lesions on the face can be associated
with no use of protective equipment or improper
use. There was also the occurrence of nose and
jaw trauma in victims who were using the helmet. The trauma to the jaw was more frequently
observed in victims who used the helmet improperly. Trauma to the face and neck were more
common in victims with no records of protective
equipment use.
Through the results of the Fisher’s exact test, it
was found a significant association of helmet use
with the Glasgow variable. For this variable, it was
observed that patients wearing helmets were associated with the mild rating (13-15 points); those
in which helmet use was considered inappropriate were associated with the moderate score (9-12
points); and the severe rating (3-8 points) was associated with those in which there was no record of
helmet use (p≤0.000).
Table 2 presents the victims of motorcycle accidents with craniocerebral trauma in relation to the
severity of trauma assessed by the Glasgow Coma
Scale with the following variables: month, age, gender, position, and site of trauma.
Regarding the severity of craniocerebral trauma
suffered by the victims, 141 (50.9%) were classified
as mild; 40 (14.4%) as moderate; and seven (2.5%)
as severe. The predominant age group of victims
Acta Paul Enferm. 2014; 27(5):485-91
487
Craniocerebral trauma in motorcyclists: relation of helmet use and trauma severity
Table 1. Distribution of victims of motorcycle accidents with craniocerebral trauma in relation to helmet use
Helmet use
Variables
Age
Gender
Position
Trauma
GLASGOW
Category
Helmet use
Yes
No
Inappropriate
Not informed
n(%)
n(%)
n(%)
n(%)
7 – 17
9(4.8)
2(1.0)
1(0.5)
3(1.6)
18 – 28
50(26.6)
6(3.2)
22(11.7)
26(13.9)
29 – 39
28(14.9)
3(1.6)
3(1.6)
9(4.8)
40 – 50
7(3.7)
1(0.5)
6(3.2)
7(3.8)
51 – 60
3(1.6)
--
1(0.5)
1(0.5)
Male
82(43.6)
9(4.8)
30(16.0)
38(20.2)
Female
15(8)
3(1.6)
3(1.6)
8(4.2)
Driver
82(43.6)
11(5.9)
30(16)
33(17.5)
Backseat
15(8)
1(0.5)
3(1.6)
13(6.9)
Skull
97(35.0)
12(4.3)
33(11.9)
46(16.6)
3(1.1)
Eye
3(1.1)
2(0.7)
2(0.7)
Nose
9(3.2)
1(0.4)
3(1.1)
3(1.1)
Jaw
10(3.6)
3(1.1)
6(2.2)
4(1.4)
Face
4(1.4)
2(0.7)
3(1.1)
8(2.8)
Dental
3(1.1)
3(1.1)
1(0.4)
2(0.8)
Neck
5(1.8)
--
3(1.1)
6(2.2)
Mild
84(44.7)
6(3.3)
14(7.4)
37(19.7)
Moderate
12(6.4)
5(2.7)
18(9.5)
5(2.7)
Severe
1(0.5)
1(0.5)
1(0.5)
4(2.1)
p-value
0.332NS
0.554NS
0.118NS
N/A
0.000*
NS – not significant; N/A – Not applicable as this is a multiple answer variable
Table 2. Distribution of victims of motorcycle accidents in relation to the severity of craniocerebral trauma by the Glasgow Coma
Scale
Glasgow
Variables
Age
Gender
Position
Trauma
Category
Mild
Moderate
Severe
n(%)
n(%)
n(%)
7 – 17
13(6.9)
2(1.1)
--
18 – 28
76(40.1)
23(12.2)
5(2.7)
29 – 39
35(18.6)
7(3.7)
5(2.7)
40 – 50
15(8.0)
5(2.7)
1(0.5)
51 – 60
2(1.1)
3(1.6)
1(0.5)
Male
119(63.3)
33(17.5)
--
p-value
0,550NS
0,723NS
Female
22(11.7)
7(3.7)
7(3.7)
Driver
114(60.6)
35(18.6)
--
0,399NS
Backseat
27(14.4)
5(2.7)
Skull
141(50.9)
40(14.4)
7(2.5)
N/A
Eye
7(2.5)
2(0.8)
1(0.4)
Nose
15(5.4)
--
--
Jaw
13(4.7)
9(3.2)
---
Face
16(5.8)
1(0.4)
Dental
3(1.1)
3(1.1)
--
Neck
15(5.4)
2(0.8)
--
NS – not significant; N/A – Not applicable as this is a multiple answer variable
with mild, moderate and severe trauma was also between 18 and 28 years.
In relation to the position in the vehicle, it was
found that 83% of victims were drivers and 17%
were in the backseat. In total, were identified 21
victims of mandibular fractures (11%) among drivers; 15 with face trauma (8%); 14 with nose trauma
(7%), followed by neck trauma in 13 (7%), denoting the inappropriate use of protective equipment.
488
Acta Paul Enferm. 2014; 27(5):485-91
Discussion
Although the results of this research are limited by
a small sample, not comprehensive of an annual assessment, data are considered to be representative
of the studied phenomenon, contributing to the
clarification of the issue, and pointing out evidence
to confirm results of other researches. Nurses participate in health care from primary to tertiary levels.
Dutra VC, Caregnato RC, Figueiredo MR, Schneider DS
The results support the planning and development
of preventive and recovery actions for the nursing
practice and may result in decreased morbidity and
mortality. When the accident occurs, nurses provide
care in all stages, engaging from pre-hospital care to
rehabilitation. Therefore, with more evidences, the
actions both on prevention and care to victims will
be better, since motorcyclists have the second highest rate of hospitalization due to traffic accidents,
second only to pedestrians.(12)
A surprising aspect of this research refers to the
fact that although in Brazil the legal minimum age
for obtaining a motorcycle license is 18 years, five
of the drivers were aged between 16 and 17 years.(13)
The profile of the study sample was of 84.6%
male, mostly aged between 18 and 28 years, which
is in line with other studies showing high rates of
accidents involving male motorcyclists,(4,5,14,15) and
their involvement in traffic accidents for being drivers of vehicles in possession of a license, who have
learned to drive when underage.(16) The age between
18 and 28 years is primarily related with driving
permission, making this a high-risk population by
the inexperience in driving, the impulsive characteristic of the age, and other factors such as consumption of alcohol and other drugs, together with poor
supervision by the State.(15) A study carried out in
the city of Fortaleza-CE with victims of motorcycle
accidents had similar results, with predominance of
the male gender, and age range between 18 and 29
years. Youngsters are more frequent victims because
they present certain sociocultural behaviors, assuming greater risk in driving.(15)
When relating the variables investigated in
this study, a more significant relationship between
helmet use and the classification of craniocerebral
trauma became evident. The majority of victims
(51.6%) which used the equipment effectively
was affected by less severe trauma, presenting the
following craniocerebral trauma classification, according to the Glasgow Coma Scale: 44.7% mild,
6.4% moderate and 0.5% severe. In cases where the
victim used the helmet inappropriately, the traumas were on average 10.7% mild, 12.2% moderate
and 1% severe, observing the double of moderate
and severe trauma percentages in these victims. The
Glasgow severe classification was higher in those
victims in which there was no recording of information on helmet use at the time of the accident.
The omission of information about the use of the
helmet at the accident site is supposedly related to
future legal barriers arising from the record of nonuse of protective equipment.
A study carried out in Australia(17) found a reduction of 66% in the probability of intracerebral
lesions for motorcyclists and cyclists who wore helmets. In another study conducted in Taiwan,(18)
motorcyclists without helmets were more than four
times more likely to suffer head injuries, and ten
times more prone to brain damage.
A study carried out in the state of Pernambuco,
in Brazil, showed that the head/neck were the second most affected body part in motorcycle drivers
treated in the emergency room after the accident,
while the effective use of helmet significantly reduced the severity of these lesions.(14,19) In another
study, in the state of Rio Grande do Norte (also in
Brazil), it was found that motorcycles were responsible for 53.2% of the accidents, with 38.8% of
motorcyclists with mild and moderate lesions, and
83.2% with mild trauma.(20) These data corroborate
the numbers found in this study and emphasize the
importance of using protective equipment for preventing lesions of greater severity.
Researchers in Michigan, United States,
studied the impact of helmet use on motorcycles
drivers with hospital costs. Despite the mandatory helmet use in this state, 19% of drivers were
not using at the time of collision. Bikers without helmets suffered more injuries in the head
and neck, and had the highest rates of serious
injury.(11) In this study, 51.6% were using the
equipment and 83% were motorcycle drivers.
In a Brazilian study carried out in Pernambuco,
80.1% were using the helmet;(14) half the drivers
in Kenya, and 20% of the backseat passengers
wore helmets;(5) in Jamaica 49.9% were wearing
helmets at the time of the accident.(4) As Brazil
is a country with great cultural differences, it is
observed that the percentages found in the present study, carried out in a city in the southern region, were different from the percentages found
Acta Paul Enferm. 2014; 27(5):485-91
489
Craniocerebral trauma in motorcyclists: relation of helmet use and trauma severity
in another study held in the northeast region;
the rates found in this study are more similar to
numbers found in Kenya and Jamaica.
In this research, in addition to patients presenting craniocerebral trauma, 89 associated injuries also occurred: eye, nose, jaw, face, dental
and neck, and the victims who were not wearing
a helmet, or lost it, had two or more traumas.
The mandatory and proper use of the safety device (helmet) by motorcyclists contributes with
lower incidence of soft tissue injuries and fractures of the face,(14,20) which was confirmed in
this study.
Failure to use helmet or its improper use constitute an illegal act, since from 1982, helmet use
became mandatory according to the Brazilian legislation. The Article 244 of the Brazilian Traffic
Code, considers the nonuse of helmet a very serious
offense, with penalties such as fines and suspension
of driving rights, and as an administrative measure, the retention of the National Driver’s License
(CNH - Carteira Nacional de Habilitação).(13) Safety equipment such as helmets are not often used by
motorcyclists, making education and supervision
measures necessary.(12)
Conclusion
This study allowed relating the helmet use with the
severity of craniocerebral trauma of injured motorcyclists who received care at a reference center in
trauma. The results showed 51.6% of motorcyclists
wore helmets at the time of accident. There was a
significant association between the Glasgow Coma
Scale evaluation and the severity of craniocerebral
trauma, showing that among bikers who correctly
used the helmet 44.7% had mild trauma, 6.4% had
moderate and severe trauma occurred in 0.5%. Victims without records of use/nonuse of helmet had
severe trauma (p≤0,000).
The highest prevalence occurred among males,
aged between 18 and 28 years, and who occupied
the position of motorcycle drivers.
It is necessary to expand educational strategies associated with effective public policies
490
Acta Paul Enferm. 2014; 27(5):485-91
and more rigorous supervision of helmet use, in
order to reduce the high rates of accidents involving motorcyclists without helmet use, since
all studies show its effectiveness by attenuating
the severity of injuries. It is also important to
raise awareness of health professionals in relation to recording the use of helmet at the time of
pre-hospital care.
Acknowledgements
We thank the institutional support received for
the study.
Collaborations
Dutra VC; Caregnato RCA; Figueiredo MRB and
Schneider DS declare to have contributed to the
project design or analysis and interpretation of data;
in drafting the article or critical revision of the relevant intellectual content; and final approval of the
version to be published.
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motorcycle crashes: a serious public health problem in Brazil. World J
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3. Philip AF, Fangman W, Liao J, Lilienthal M, Choi K. Helmets prevent
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4. Crandon IW, Harding HE, Cawich SO, McDonald AH, Fearron-Boothe
D. Motorcycle accident injury profiles in Jamaica: an audit from the
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5. Saidi H, Mutisto B. Motorcycle injuries at a tertiary referral hospital in
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Acta Paul Enferm. 2014; 27(5):485-91
491
Original Article
Nursing actions in homecare to
extremely low birth weight infant
Ações de enfermagem na assistência domiciliar
ao recém-nascido de muito baixo peso
Anelize Helena Sassá1
Maria Aparecida Munhoz Gaíva2
Ieda Harumi Higarashi3
Sonia Silva Marcon3
Keywords
Pediatric nursing; Maternal-child
nursing; Infant, very low birth weigth;
Home nursing; Nursing care
Descritores
Enfermagem pediátrica; Enfermagem
materno-infantil; Recém-nascido
de muito baixo peso; Assistência
domiciliar; Cuidados de enfermagem
Submitted
July 10, 2014
Accepted
July 29, 2014
Corresponding author
Sonia Silva Marcon
Colombo Avenue, 5790, Maringá, PR,
Brazil. Zip Code: 87020-900
[email protected]
Abstract
Objective: To describe nursing actions implemented in a home context for the needs presented by the families
of extremely low birth weight newborns.
Methods: This convergent care research was carried out with nine families who were visited in their home. For
data collection we used semi-structured informal interviews and observation of participants during the first six
months after hospital discharge. Data were analyzed using the thematic modality.
Results: Care needs of families during daily home care were related mainly to doubts and insecurities specific
to extremely low birth weight premature babies and the care and guidance required for follow-up of newborns
in general.
Conclusion: Nursing actions in a home context involve child evaluation, guidance, demonstrations,
clarifications, referrals, and stimulation for puericulture follow-up with specialists. These actions also include
facilitating family empowerment and gradual autonomy of care.
Resumo
Objetivo: Descrever as ações de Enfermagem implementadas no contexto domiciliar, a partir das necessidades
apresentadas pelas famílias de bebês nascidos muito baixo peso.
Métodos: Pesquisa convergente-assistencial realizada com nove famílias, por meio de visitas domiciliares,
entrevistas informais, semiestruturadas e observação participante, durante os 6 primeiros meses após a alta
hospitalar. Os dados foram submetidos à análise de conteúdo, modalidade temática.
Resultados: As necessidades assistenciais das famílias durante o cuidado cotidiano no domicílio estiveram
relacionadas principalmente a dúvidas e inseguranças advindas da prematuridade e do muito baixo peso, aos
cuidados específicos e à orientação quanto ao seguimento dos bebês.
Conclusão: As ações de Enfermagem no contexto domiciliar envolveram avaliação da criança, orientações,
demonstrações, esclarecimentos, encaminhamentos e estímulo para o acompanhamento de puericultura e
com especialistas, além de uma abordagem que facilitou o empoderamento familiar e a autonomia gradativa
para o cuidar.
Secretaria Municipal de Maringá, Maringá, PR, Brazil.
Universidade Federal de Mato Grosso, Cuiabá, MT, Brazil.
3
Universidade Estadual de Maringá, Maringá, PR, Brazil.
Conflicts of interest: none reported.
1
DOI
http://dx.doi.org/10.1590/19820194201400080
492
Acta Paul Enferm. 2014; 27(5):492-8
2
Sassá AH, Gaíva MA, Higarashi IH, Marcon SS
Introduction
Methods
Premature infants with extremely low birth weight
(≤1500g) are becoming more frequent. Worldwide,
almost 14 million children are born prematurely
every year, meaning that more than 1 in 10 births
are pre-term.(1) This is mainly due to improvements
in obstetric care and the increase in multiple gestations stemming from more access to and use of
assisted reproduction.(2)
The health of these babies becomes compromised soon after birth. They are exposed to a variety
of risks related to their weight and gestational birth
age; they require intensive care, as well as systematic
follow-up of growth and development for long periods. This follow-up helps improve their prognosis
in the face of increased vulnerability due to chronic
conditions from childhood to adolescence.(3,4)
Although technological advances in neonatal
care have helped improve survival of even smaller
and more immature babies, follow-up of these children after discharge is indispensable. (5) However, in
Brazil, this follow-up is limited and little is known
about how often it occurs; in addition, few studies
have addressed the interventions implemented for
these babies and their families at home.(6)
The importance of hospital care for these children, care in daily life, daily duties at home, and
regular, multidisciplinary follow-up after hospital
discharge are critical for satisfactory growth and development, despite the limitations that might exist.
For this reason, it is fundamental that health
professionals identify the needs of low birth weight
children, state goals for their care, and support
mothers and families with demands of home care.
(7)
In the home context, nurses have an important
role for providing guidance and support to the
family, particularly the mother, for daily life care,
and these professionals must ensure individualized, continuing care that is adapted to the family’s
specific needs.
Because care after hospital discharge is fundamental for maintenance of the baby’s health, this
study sought to describe nursing actions implemented in the homes of families of extremely low
birth weight newborns.
This descriptive study with a qualitative approach
used a convergent care research method.(8) Participants were nine families of extremely low birth
weight newborns from the surveillance program of
Baby at Risk in May to October 2010. The study
was conducted in the city of Maringá, state of
Paraná, in the southern region of Brazil. We included babies whose birth weight was ≤1.500g.
Data were collected from June 2010 to August 2011 by informal interviews and observation of participants during home visits in the
first 6 months after hospital discharge that were
scheduled according to care plan or at least once
a month. The first contacts with families occurred
during babies’ hospitalization, over the phone, at
a hospital visit, or at home. Visits were previously
scheduled according to the established care plan or
at least one a month.
Follow-up and nursing care were done in person, over the phone, and electronically and was
based on needs that emerged during each contact.
Activities covered included guidance, clarification
of doubts, management of breastfeeding, demonstration of care and procedures, physical exams, and
assessment of child’s growth and development.
Perceptions concerning the doubts and needs of
families and nursing management observed in the
families’ presence were recorded in a field diary and
were submitted to content analysis (thematic modality). Some of notes in the diary are used here
to represent inferences from data analysis. Development of this study followed all national and international ethical and legal aspects of research on
human subjects.
Results
The 10 babies in this study were born via cesarean
deliver, weighed 655g to 1,479g, and were maintained in a neonatal intensive care unit for 15 to
109 days. All mothers were allowed to assume the
care of their babies with regard to feeding and hygiene during hospitalization.
Acta Paul Enferm. 2014; 27(5):492-8
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Nursing actions in homecare to extremely low birth weight infant
Content analysis of nursing care records identified the category “Clarifying doubts, supporting
families in daily life care”. Families of extremely low
birth weight babies shared the same idea: that the
child, because of the birth conditions and long term
hospital stay, must receive care that differs from
that given to other children in the family in order
to protect them and address their special needs for
attention and care.
In the first days after discharge, families were
concerned about continuing the care that the
baby received during hospitalization, protecting
the baby from infections, and identifying possible
intercurrences early (italicized text was obtained
from the nurses’ field notes; the identified theme
is also listed).
Because of the fragility of babies and intercurrences
that had already occurred, mothers were insecure and
afraid of not perceiving whether the child was not well.
They did their best to be awake during night and to
be constantly alert. (Family strength and carefulness,
first days after discharge).
For the anxiety showed by families, guidance
was offered to prevent harms and promote health.
In addition, for the doubts and experience faced by
the families, we created and distributed explanatory
pamphlets to help them identify possible signs and
symptoms of harms to the baby’s health. Although
each family had a specific doubt, pamphlets were
produced and distributed to all families participating in the study in order to be provide equal benefit
with guidance.
Families were concerned about protecting the
child from disease through vaccination. Therefore, during all visits, the brochure about child
health was verified and parents were guided on
the disease prevented by each vaccine, possible
vaccine reactions, and eventual side effects. Vaccine reactions, such as fever, reduced appetite,
pain and irritation at the injection site, and apathy, were common in the babies, and parents
requested help from the nurses regarding what
actions they should take to prevent or attenuate
such reactions:
The mother asked if the second dose of the vaccine
would cause more reactions and what she must do if
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Acta Paul Enferm. 2014; 27(5):492-8
they appeared. (Family carefulness, 3 months and 22
days after discharge).
The stimulus to obtain follow up of the baby
with a specialist was also a main focus of nursing
homecare. The nurses informed the families about
the importance of these follow-up and puericulture
visits in a basic health unit for late diagnosis, treatment, and prevention of dysfunction associated
with the extremely low birth weight and high-complexity therapy used during hospitalization:
Although the mother already had the referral for
ophthalmology consultation, she still had not scheduled
the medical visit. She did not know the risks of retinopathy in prematurity. (Family carefulness, 23 days
after discharge).
In addition, it was often necessary to guide families to help them to overcome barriers to scheduling medical follow-ups due to difficulty accessing
the service and lack of training of professionals that
provide support in basic care units:
The mother went to the basic health unit to schedule ophthalmoscopy [...] but the nurse thought that
the mother was requesting the red reflex test. (Family
friendship, 19 days after discharge).
After medical visits, parents felt they needed
more clarification concerning information on their
babies’ clinical conditions or the exams conducted:
The mother was concerned because on skull ultrasonography a ventricular cyst appeared. [...] She wants
to understand what that meant. (Family carefulness,
1 month and 14 days after discharge).
In addition, when mothers returned home
with a prescription for a new medicine, they did
not understand the importance of correctly following the treatment and requested explanations
about its effects:
The baby was receiving an inhaled medication six
times a day [...] The mother perceived improvement
and decided by herself to reduce administration to four
times a day. Soon the child returned presenting effort
with breathing [...] After that, the mother asked about
the reason for those medicines. (Family friendship, 4
months and 20 days after discharge).
In the case of the theme of family love, nursing
follow-up at home enabled detection of shortcomings in the treatment prescribed for the baby be-
Sassá AH, Gaíva MA, Higarashi IH, Marcon SS
cause an important medicine, prescribed at hospital
discharge, was not being administered:
[...] I found that in some papers of the baby a
prescription of phenobarbital – administer 17 drops
once a day. I asked why that medicine was not being
administered and the mother reported that when she
brought the prescription to the health unit pharmacy
they said the medicine was to control her anxiety, and
she thought it was not necessary because she was feeling
well. (Family love, 4 days after discharge).
Mothers’ doubts were present at all follow-up
periods, and these doubts were related to issues concerning hygiene/comfort and signs and symptoms
presented by the babies. During physical exam and
anthropometric measurement of babies conducted
at home, mothers, parents and relatives took the
opportunity to clarify doubts that emerged during
the child’s care. They asked about such issues as fontanelle and sutures, the structure and development
of the ears, and changes in the skin:
The mother observed that some parts of the child’
skull were softer [...]. I explained that sutures and fontanelle were still not totally calcified and asked her to
touch them in order to understand this better. (Family
carefulness, 1 month and 17 days after discharge).
Homecare also served to address families’ requests for support during intercurrences, for evaluations of the babies, for guidance, and for referral
for needs detected:
The mother, concerned, called and requested me to
go to her house. The baby was vomiting and refused to
breastfeed [...] The diaper had little mucous and small
blood spots. [...] I explained to her that something can
be affecting her bowel mucus.[...] I instructed her to
keep ad libitum breastfeeding and to visit the pediatrician and to continue the observation. The next day, the
mother called saying that the pediatrician confirmed
all the information I gave her and prescribed only
analgesics and observation. (Family affection, two
months and eight days after discharge).
On the previous day, the child had apnea, cyanosis
and hypotonia during a bath and the mother was very
scared [...] I realized that she wanted me to follow up
the baby’s bath, and she waited to give a bath to the
baby during the home visit. (Family friendship, 21
days after hospital discharge).
Discussion
Limitations of this study are related to the methodological approach and small number of participants. For this reason, the results cannot be extrapolated to other populations.
However, the use of convergent care research, besides constituting a differential approach, enabled
us to enhance the comprehension of needs for
professional care presented by families of extremely low birth weight infants and possible actions to
be developed in the home context. Therefore, our
study contributed to nursing practice because it evidenced the need for improvement in nursing actions provided to the follow-up of these infants and
their families at home.
The study data showed that mothers and other family members associated extremely low birth weight
to a more fragile condition and an increased probability of severe disease even after hospital discharge.
This association was the main reason for anxiety,
apprehension, and insecurity, which affected families for long periods, and also caused doubts concerning the delivery of care to the babies at home.
Hence, in the first day at home after discharge of
the baby, families were worried about meeting the
needs of the child, especially given what they experienced during hospitalization; these fears facilitated care but did not prevent anxiety related to their
baby’s fragility.
Adequate preparation of families for discharge,
stimulation and reinforcing the parents’ trust in
their ability to take care of the child at home is extremely important.(9-11) However, it is imperative
that the baby’s clinical picture is stable, that parents
have adequate physical and emotional reserves, and
that parents have access to a service network that
can be easily reached in case of any intercurrence
and that offers support for the family to implement
home care.(12)
Families’ doubts in relation to signs and symptoms presented by the baby, the baby’s characteristics, and risks and weakness were related to daily
care at home. This home care required that families
make continuous decisions that previously were
guided by hospital staff. Many parents perceived
Acta Paul Enferm. 2014; 27(5):492-8
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Nursing actions in homecare to extremely low birth weight infant
that, even after discharge, the baby had health risks
and that, despite the advanced clinical stability, the
threats of intercurrences and harms persisted(13).
In addition, even facing a long period of experience in the hospital environment before the discharge, we believe that the mother had gone through
enough care situations to guide her in taking care of
the child, but the reality at home is quite different.
In the hospital the mother has the constant support
of professionals, whereas at home she is often alone.
Even mothers with other children associate prematurity with fragility of the baby, which triggers the
need for specific and differentiated care; such care
is possible by the extension of professional support
at home.(14)
To reduce these situations, guidance on particularities of extremely low birth weight babies was
given. The assistance might be provided in a conventional manner that respected the context of the
baby’s family and cultural practices. Homecare may
favor promotion and protection of physical care
and development of these children, who, without a
doubt, had higher risks of changes related to birth
weight.(15)
A study that sought to identify difficulties perceived by mothers with regard to care of low birth
weight infants and resources used to address health
intercurrences showed that situations interpreted by
mothers as “dangerous” were associated with great
fear and, for this reason, constituted a reason to seek
professional support.(7) In this context, the planned
discharge along with family and home visits of
nurses helped reduce anxiety and fear.(16)
Home care is based on interaction among
health professionals, patients and their relatives,
and it seeks to improve the autonomy and highlight
skills of individuals by using educational actions,
demonstration and/or execution of procedures in
the families environment – their homes.(17,18) In patients’ home, the professionals can understand the
reality of the supported individuals, recognize their
problems and needs(17) and, in this way, adapt the
knowledge and technical procedures to home care.
In case of extremely low birth weight babies,
the constant contact with the family at home enables the nurse to be closer to the family,(19) so that
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Acta Paul Enferm. 2014; 27(5):492-8
the professional can plan assistance that is based on
the real needs of each family and is consonant with
the context in which the child and family live. It
can also strengthen the bond between parents and
baby.(20) Our study results highlighted that nurse actions to support, guide, and assist families at home
reduced the insecurity and fear that are common
within the first months after discharge. As a result,
the nurses strengthened the families to provide the
specific care that these babies need.
Reports in the literature emphasize that families felt more prepared and more secure in taking care of premature baby when they receive
adequate support of a multidisciplinary team.(21)
Indeed, home care enabled the creation of strong
bonds and mutual trust between professionals
and families, thereby reducing suffering and increasing support of the family,(21) offering strength
and support for care,(13) and helping reduce the
morbidity and mortality of extremely low birth
weight infants.
A randomized study in families of premature
babies that conducted home visits during the first
year of life showed long-term benefits of professional care at home related to lower risk of anxiety among caregivers when children already had
reached preschool age; in addition, the intervention
showed positive effects on the behavior and mental
status of children.(22)
Nursing homecare in the studied context enabled families to feel secure and trust the care delivery by nurses. The bond enabled mothers to feel
free to request professional support. When mothers
felt supported to face problems that appeared while
caring for the baby at home, families experienced a
new opportunity of learning that probably would
be not possible at outpatient unit visit.
In our study, we found that nurses who availed
themselves of information obtained from families
during medical visits used a more accessible posture
and language, answered questions that emerged,
and enabled parents to better comprehend what
was occurring with the baby. When mothers became calmer and better informed as a result of the
nurses’ approach, they were able to be more attentive to identifying any specific care need.
Sassá AH, Gaíva MA, Higarashi IH, Marcon SS
Nurse’s sensibility and listening were important
to identify families’ anguish. The availability of time
to share care at home between nurse and family and
the valorization of anxieties, doubts, and uncertainty enabled nurses to better understand the meaning
of the experience according to the family’s point of
view. In addition, it allowed nurses to plan actions
with families, reduce their anguish, and eliminate
difficulties found during care after the baby’s hospital discharge. Therefore, nursing homecare constitutes a key component for intervention for those
taking care of extremely low birth weight babies.(10)
This support is extremely important because
families of extremely low birth weight babies, as
a unit responsible for care, need to feel supported
and protected after leaving the hospital environment in order to transition from the institutional environment to home environment, and from
professional care to family care. Such transition
must be done in a safe and calm manner, moderated by the presence and action of nurses in this new
context of life and care.
manuscript. Gaíva MAM and Higarashi IH contributed to critical revision of important intellectual content. Marcon SS participated in project
design, executing the research, critical revision of
important intellectual content and final approval
of the version to be published.
Conclusion
6. Vieira CS, Mello DF. [The health follow up of premature and low birth
weight children discharged from the neonatal intensive care unit]. Texto
& Contexto Enferm. 2009; 18(1):74-82. Portuguese.
Nursing actions in the home context involved the
assessment of the child, guidance, demonstrations,
clarifications, referrals, and stimulation for puericulture follow-up and consultation with specialists. They also involve an approach that facilitates
empowering the family and gradual autonomy in
delivery of care.
7. Fonseca EL, Marcon SS. [Mother’s perception about homecare
delivered to her low-weight infant]. Rev Bras Enferm. 2011; 64(1):117. Portuguese.
Acknowledgements
To the National Council for Scientific and Technological Development (CNPq) for the finance
support given to research project and for the scholarship to Sonia Silva Marcon and to the Coordination for the Improvement of Higher Education Personnel (CAPES) for the scholarship given to Master
Degree Studies of Anelize Helena Sassá.
Collaborations
Sassa AH declare that contributed to the project
design, executing the research and drafting the
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