APE 27(2) ingles.indb
Transcription
APE 27(2) ingles.indb
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(2), March/April 2014 ISSN: 1982-0194 (electronic version) Frequency: Bimonthly Phone: +55 11 5576.4430 Extensions 2589/2590 E-mail: [email protected] Home Page: http://www.unifesp.br/acta/ Facebook: facebook.com/ActaPaulEnferm Twitter: @ActaPaulEnferm Tumblr: actapaulenferm.tumblr.com Editorial Council Editor-in-Chief Sonia Maria Oliveira de Barros Acta Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil Technical Editor Edna Terezinha Rother Acta Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil Associate Editors Department of Administration and Public Health Ana Lucia de Moraes Horta, 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 Department of Medical and Surgical Nursing Bartira de Aguiar Roza, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil Edvane Birelo Lopes De Domenico, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil João Fernando Marcolan, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil Ruth Ester Assayag Batista, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil Department of Pediatric Nursing Ariane Ferreira Machado Avelar, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil Maria Magda Ferreira Gomes Balieiro, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil Department of Women’s Health Nursing Erika de Sá Vieira Abuchaim, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil Rosely Erlach Goldman, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil 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 I 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 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 Tracy Heather Herdman, Boston College, Massachusetts, USA Editorial Office Bruno Henrique Sena Ferreira Maria Aparecida Nascimento Graphic Design Adriano Aguina Acta Paulista de Enfermagem – (Acta Paul Enferm.), has as its mission the dissemination of scientific knowledge generated in the rigor of the methodology, research and ethics. The objective of this Journal is to publish original research results to advance the practice of clinical, surgical, management, education, research and information technology and communication. Member of the Brazilian Association of Scientific Editors II Universidade Federal de São Paulo President of the Universidade Federal de São Paulo Soraya Soubhi Smaili Vice-President of the Universidade Federal de São Paulo Valeria Petri Dean of the Escola Paulista de Enfermagem Sonia Maria Oliveira de Barros Vice-Dean of the Escola Paulista de Enfermagem Heimar de Fátima Marin Departments of the Escola Paulista de Enfermagem Administration and Public Health Anelise Riedel Abrahão Medical and Surgical Nursing Rosali Barduchi Ohl Pediatric Nursing Myriam Aparecida Mandetta Women’s Health Nursing Ana Cristina Freitas Vilhena Abrão Completion Support All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License. With a view tward sustainability and accessibility, Acta Paulista de Enfermagem is published exclusively in the digital format. III Editorial T he structure of an original scientific paper is usually composed of four parts: introduction, methods (or materials and methods), results and discussion. Each provides one type of information, and the whole should make the reader understand the research and its conclusion. In the analysis of texts submitted for publication, the methods section often needs to be reworked. This section will be the focus of this editorial. The function of the methods section is to inform the reader how the study was conducted. When properly prepared, it provides information to enable replication of the research. Several topics compose the methods section in an original article: the type of study, which will be discussed in the next paragraph; the research scenario, with date, location and characteristics; the participants who comprise the study sample; and data collection. Additionally, there are: ethical issues, analyses and interventions, which are described when relevant. The research plan is understood by the study type, development or its design. It is the path adopted to arrive at the results. Some types of study are quite well known. One must only mention their names so that the reader knows what they are; for example, a cross-sectional study. This information also helps the reader to evaluate the potential of the design to achieve the study objectives. It is possible that complex, new or little known designs require additional explanations, accompanied by bibliographic references. There are writing guides for each design that are compiled on the site: www. equator-network.org/. In some reports, there is no mention of design or we are simply informed that the study is qualitative or quantitative. It is necessary to clarify which type of qualitative or quantitative study. The mere mention of one of these awakens in the reader, who is knowledgeable of the matter, details of the theory on the subject, in particular, its strengths and limitations. Comprehensive and clear information about the materials and methods used enrich the story. The readers will appreciate it if they are awarded with such information. Mauricio Gomes Pereira Professor Emérito, Universidade de Brasília DOI: http://dx.doi.org/10.1590/1982-0194201400017 IV Contents Original Articles Alcohol consumption pattern among workers and socioeconomic profile Padrão de consumo de bebidas alcoólicas entre os trabalhadores e perfil socioeconômico Riany Moura Rocha Brites, Ângela Maria Mendes de Abreu����������������������������������������������������������������������������������������������������� 93 Root cause analysis of falling accidents and medication errors in hospital Análise de causa raiz de acidentes por quedas e erros de medicação em hospital Thalyta Cardoso Alux Teixeira, Silvia Helena de Bortoli Cassiani�������������������������������������������������������������������������������������������� 100 Interpersonal Communication Competence Scale: Brazilian translation, validation and cultural adaptation Validação e adaptação cultural para o português da Interpersonal Communication Competence Scale Ana Cláudia Puggina, Maria Júlia Paes da Silva����������������������������������������������������������������������������������������������������������������������� 108 Characterization of the intrahospital transport of critically ill patients Caracterização do transporte de pacientes críticos na modalidade intra-hospitalar Silmara Meneguin, Patrícia Helena Corrêa Alegre, Claudia Helena Bronzatto Luppi��������������������������������������������������������������� 115 Association between sleep disorders and frailty status among elderly Associação entre transtornos do sono e níveis de fragilidade entre idosos Ariene Angelini dos Santos, Maria Filomena Ceolim, Sofia Cristina Iost Pavarini, Anita Liberalesso Neri, Mariana Kátia Rampazo���������������������������������������������������������������������������������������������������������������������������������������������������������� 120 Revelations expressed by preschool children with chronic diseases in outpatient treatment Revelações manifestas por crianças pré-escolares portadoras de doenças crônicas em tratamento ambulatorial Ana Paula Keller de Matos, Priscilla Caires Canela, Aline Oliveira Silveira, Monika Wernet���������������������������������������������������� 126 Level of knowledge, attitudes and practices of puerperal women on HIV infection and its prevention Grau de conhecimento, atitudes e práticas de puérperas sobre a infecção por HIV e sua prevenção Raquel Ferreira Gomes Brasil, Maysa Mayran Chaves Moreira, Liana Mara Rocha Teles, Ana Kelve de Castro Damasceno, Escolástica Rejane Ferreira Moura������������������������������������������������������������������������������������������������������������������������������������������� 133 Opinion of nursing students on realistic simulation and the curriculum internship in hospital setting Opinião dos estudantes de enfermagem sobre a simulação realística e o estágio curricular em cenário hospitalar Alessandra Freire Medina Valadares, Marcia Cristina da Silva Magro��������������������������������������������������������������������������������������� 138 Contamination rate of blood tests and its determining factors Taxa de contaminação de testes hematológicos e seus fatores determinantes José Enrique De La Rubia-Ortí, Gemma Verdu-Tresoli, Vicente Prado-Gascó, Pablo Selvi-Sabater, Joao Firmino-Canhoto��������� 144 Moral harassment experienced by nurses in their workplace Situações de assédio moral vivenciadas por enfermeiros no ambiente de trabalho Graziela Ribeiro Pontes Cahú, Solange Fátima Geraldo da Costa, Isabelle Cristinne Pinto Costa, Patrícia Serpa de Souza Batista, Jaqueline Brito Vidal Batista���������������������������������������������������������������������������������������������������������������������������������������������������� 151 V Quality of life before and after bariatric surgery Qualidade de vida antes e após a cirurgia bariátrica Josiane da Motta Moraes, Rita Catalina Aquino Caregnato, Daniela da Silva Schneider��������������������������������������������������������� 157 Smoking, alcohol consumption and physical activity: associations in acute coronary syndrome Tabagismo, consumo de álcool e atividade física: associações na síndrome coronariana aguda Evelise Helena Fadini Reis Brunori, Agueda Maria Ruiz Zimmer Cavalcante, Camila Takao Lopes, Juliana de Lima Lopes, Alba Lucia Bottura Leite de Barros����������������������������������������������������������������������������������������������������������������������������������������� 165 Content validation of the nursing intervention called Environmental Control: worker safety Validação de conteúdo da intervenção de enfermagem Controle Ambiental: segurança do trabalhador Francisca Sánchez Ayllón, Adriana Catarina de Souza Oliveira, Isabel Morales, Jéssica Dantas de Sá, Paloma Echevarría Pérez��������������������������������������������������������������������������������������������������������������������������������������������������������� 173 Oncoaudit: development and evaluation of an application for nurse auditors Oncoaudit: desenvolvimento e avaliação de aplicativo para enfermeiros auditores Luciane Mandia Grossi, Ivan Torres Pisa, Heimar de Fátima Marin���������������������������������������������������������������������������������������� 179 Analysis of hemorrhage at vaginal delivery by erythrocyte and hematocrit indices Análise da hemorragia no parto vaginal pelos índices de eritrócitos e hematócrito Maria Cristina Gabrielloni, Cláudia Junqueira Armellini, Márcia Barbieri, Janine Schirmer��������������������������������������������������� 186 VI Original Article Alcohol consumption pattern among workers and socioeconomic profile Padrão de consumo de bebidas alcoólicas entre os trabalhadores e perfil socioeconômico Riany Moura Rocha Brites1 Ângela Maria Mendes de Abreu2 Keywords Alcoholism; Alcohol drinking; Workers; Occupational health; Occupational health nursing Descritores Alcoolismo; Consumo de bebidas alcoólicas; Trabalhadores; Saúde do trabalhador; Enfermagem do trabalho Submitted March 13, 2014 Accepted March 26, 2014 Corresponding author Riany Moura Rocha Brites Maurício Joppert street, unumbered, Rio de Janeiro, RJ, Brazil. Zip Code: 21941-614 [email protected] DOI http://dx.doi.org/10.1590/19820194201400018 Abstract Objective: Estimate the consumption pattern of alcoholic beverages and the socioeconomic profile of workers at a Public Service. Methods: Cross-sectional study, involving 322 subjects who answered the Alcohol Use Disorders Identification Test (AUDIT) and questions related to the sociodemographic variables. The data were processed and analyzed using the Epi-Info software. Results: It was observed that the consumption of 12.7% was classified as hazardous, harmful and suggestive of dependence. Binge drinking was found in 32.5% and 5.3% had already caused problems for themselves or others. The majority has not consumed alcohol in the previous 12 months, but those that did so consumed large quantities and frequently. Conclusion: The results showed a high prevalence of hazardous, harmful consumption and probable dependence, associated with male workers and low education levels. Resumo Objetivo: Estimar o padrão de consumo de bebidas alcoólicas e o perfil socioeconômico dos trabalhadores de um Serviço Público. Métodos: Estudo transversal realizado com 322 sujeitos que responderam ao Alcohol Use Disorders Identification Test (AUDIT) e às perguntas referentes às variáveis sociodemográficas. Os dados foram processados e analisados por meio do Epi-Info. Resultados: Observou-se que 12,7% fizeram consumo de risco, nocivo e provável dependência. O consumo pesado episódico foi de 32,5%, e 5,3% já causaram problemas a si mesmos ou a outros. A maioria não consumiu álcool nos últimos 12 meses, porém aqueles que consumiram o fizeram em quantidade e frequência elevada. Conclusão: Os resultados mostraram elevada prevalência do padrão de consumo de risco, nocivo e provável dependência associada aos trabalhadores do sexo masculino e ao baixo nível de escolaridade. Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil. Escola de Enfermagem Anna Nery, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil. Conflicts of interest: no conflicts of interest to declare. 1 2 Acta Paul Enferm. 2014; 27(2):93-9. 93 Alcohol consumption pattern among workers and socioeconomic profile Introduction The World Health Organization considers alcohol consumption as a severe Public Health problem nowadays, ranking third among the main health risk factors around the world. It is estimated that about two billion people around the world consume alcohol and that 76.3 million who do so are diagnosed with a mental disorder (dependence), representing 4% of all years of useful life lost.(1) Ten years ago, harmful alcohol consumption was responsible for 3.8% of the global mortality rate and was considered one of the main risk factors for neuropsychiatric disorders and non-transmissible diseases, such as cardiovascular diseases, liver cirrhosis and some types of cancer.(1) Binge drinking affects 11.5% of alcohol consumers and is responsible for serious health problems in accordance with the 2010 global report on alcohol. Per capita alcohol consumption around the world ranges between 4.3 and 4.7 liters per year, against 9.5 in Europe. In the Americas, this rate stabilized at around 6.7 liters in recent years.(2) In Brazil, the alcohol consumption pattern reveals preoccupying rates: on average, six liters of pure alcohol are consumed per capita per year. The hazardous pattern is one of the highest in the world. The prevalence rates of both acute consequences, such as violence and accidents, and chronic consequences are very high, considering that a significant part of the people drink too much or become dependent.(3) In addition, there is disbelief in the possibility that patients with alcohol-related problems will get better. The prevention and promotion approach of harmful alcohol consumption and abuse is rarely put in practice at the health services, who mostly deal with patients who are already alcohol-dependent.(4) In that sense, authors observe that high alcohol consumption reduces the workers’ performance, resulting in increased unemployment and low income when compared to more limited and less frequent 94 Acta Paul Enferm. 2014; 27(2):93-9. use. This consumption entails problems in the organization of the work process.(5,6) This consumption is often an attempt to escape from mental suffering and an emotional burden, linked with or deriving from the job conditions and work organization the company imposes, turning the consumption into an exit, which induces to severe cases of alcohol dependence.(7) This problem indicates the need to set up occupational health promotion and disease prevention strategies, within each service’s reality, to mitigate the problems deriving from alcohol abuse for the workers, families and the company. The Occupational Health Service could evaluate the workers’ alcohol consumption patterns, serving as an important primary and secondary prevention opportunity.(8,9) In this context, the early detection of the alcohol consumption pattern among workers demands further investigation in order to better set up specific prevention and health promotion strategies in Occupational Health Services. The objective in this study is to estimate the alcohol consumption pattern among workers at a Health Service of a university and their socioeconomic profile. Methods A cross-sectional study with random sampling was undertaken at an Occupational Health Service of a public university in Rio de Janeiro, in the Brazilian Southeast. The partial sample was based on the total number of patients attended at the service in 2011 (6,252). Based on this number, the sample size was assumed with a 3% percentage error: a proportion of 10% of the population the occupational health nurse attended in 2011, estimating a 95% confidence interval, which resulted in a sample of 362 workers attended at the Occupational Health Service between August 2011 and March 2012. All active public servants of the university, male and female, who visited the service during the study Brites RM, Abreu AM period and were attended by the researcher as part of the Occupational Health Service screening were included in the study. Workers who had already answered the form during the first consultation; who were going through admission or resignation procedures; who had consumed alcohol at the moment of the interview; workers with mental disorders; workers from other institutions and retired workers were excluded. Thus, the final sample consisted of 322 subjects. The instrument used was the Alcohol Use Disorders Identification Test (AUDIT), which consists of ten questions about the use of alcoholic beverage in the previous years, symptoms of dependence and alcohol-related problems. Workers who scored between zero and seven on the AUDIT were considered low-risk, while workers who scored more than eight were classified as hazardous, harmful consumption and probable dependence. Variables related to the workers’ socioeconomic and occupational profile were added to this questionnaire. The questionnaire template and the data were processed and analyzed using the software Epi-Info (version 3.5.1) for statistical treatment, besides univariate and bivariate analyses, based on descriptive statistics, and displayed as absolute and relative frequencies. The workers classified as dependent consumers were forwarded and monitored at the university’s specialized service. The development of the study complied with Brazilian and international ethical standards for research involving human beings. Results Hazardous, harmful consumption and probable dependence were identified in 12.7% of the servants, while 87.3% informed low-risk consumption. As presented in table 1, statistically significant differences were found for the gender and education variables, showing higher rates of hazardous, harmful consumption and probable dependence among male individuals (65.9%) when compared to women (34.1%), with p=0.01. Table 1 shows that the items of the servants’ alcohol consumption pattern, who were attended at a university’s Occupational Health Service, distributed according to the score category obtained on the AUDIT, revealed statistical significance for most items. Table 1. Socioeconomic variables associated with alcohol consumption Low-risk consumption (n=281) n(%) Hazardous, harmful consumption and probable dependence (n=41) n(%) p-value* Male 93 (33.1) 27 (65.9) <0.01 Female 188 (66.9) 14 (34.1) Variables Gender Age range, years 18-35 38 (13.5) 3 (7.3) >36 243 (86.5) 38 (92.7) Married 175 (62.3) 24 (58.5) Note married 106 (37.7) 17 (41.5) Higher Education or more 116 (41.3) 26 (63.4) Up to Secondary 165 (58.7) 15 (36.6) 0.265 Marital situation 0.645 Education <0.01 Per capita income Up to 2 wages (R$510,00) 69 (24.6) 14 (34.1) More than 2 wages (R$510,00) 212 (75.4) 27 (65.9) 0.189 * Pearson’s chi-square test Table 2 shows that 53.7% of the low-risk consumers consumed alcohol between two and four times per month and that 29.3% did so twice or thrice per week, that is, most workers indicated they had not consumed alcohol in the previous 12 months, but those who did consumed alcohol more frequently. As regards the number of drinks consumed per day, 56.1% of the hazardous consumption workers indicated they had consumed ten or more doses, followed by 24.4% who had consumed five to six standard doses. The frequency of consuming five or more standard doses on a single occasion among the workers with low-risk consumption is noteworthy: 29.5% reported consuming this quantity sometimes. The indicators of hazardous consumption (AUDIT≥8) in the audit questionnaire showed that 37.1% were unable to stop drinking, 26.8% failed to do what was normally expected because of drinkActa Paul Enferm. 2014; 27(2):93-9. 95 Alcohol consumption pattern among workers and socioeconomic profile Table 2. Alcohol consumption in the previous year Variables Low-risk consumption n(%) Hazardous, harmful consumption and probable dependence n(%) people due to drinking and 51.2% had received the suggestion to stop drinking in the last 12 months. p-value* Discussion Consumption frequency Never 159(56.6) 0(0) Monthly or less 69(24.6) 0(0) 2 to 4 times per month 49(17.4) 22(53.7) 4(1.4) 12(29.3) 0(0) 7(17.1) 2 to 3 more times per week 4 or more times per week Number of standard doses *** on a typical day 1-2 58(47.5) 0(0) 3-4 46(37.7) 6(14.6) 5-6 15(12.3) 10(24.4) 7-9 2(1.6) 2(4.9) 10 or more 1(0.8) 23(56.1) Never 86(70.5) 0(0) Sometimes 36(29.5) 41(100) Frequency of five or more standard doses <0.01 Frequency of not being able to stop drinking Never Sometimes <0.01 33(91.7) 28(68.3) 3(8.3) 13(31.7) Failed to do what was normally expected because of drinking Never Sometimes <0.01 35 (97.2) 30 (73.2) 1(2.8) 11(26.8) <0.01 Need for alcoholic drink in the morning Never Less than monthly 36(100) 37(90.2) 0(0) 4(9.8) <0.01 Feeling of guilt after drinking Never 32(88.9) 20(48.8) Sometimes 4(11.1) 10(51.2) Inability to remember what happened the night before because of drinking Never Com alguma frequência <0.01 35(97.2) 25(61) 1(2.8) 16(39) Caused loss or injury to oneself or another person because of drinking Never Sometimes <0.01 8(2.8) 9(22) 273(97.2) 32(78) Has anyone suggested you should stop drinking <0.01 Yes 14(5) 21(51.2) No 267(95) 20(48.8) *Pearson’s chi-square test ing, 51.2% felt guilt or remorse after drinking and 39% were unable to remember what had happened after drinking. Among the workers with hazardous, harmful risk consumption and probable dependence, 22% caused some loss or injury to themselves or other 96 Acta Paul Enferm. 2014; 27(2):93-9. Among the study limitations, we can include the fact that the workers were afraid that the results would interfere in the decisions about leaves and medical examinations, not revealing the actual alcohol consumption in the last 12 months before the interviews, although the research participants’ anonymity was preserved. Nevertheless, we acknowledge the limitations of cross-sectional studies, which do not permit the establishment of cause and effects relations. Our results contribute for the occupational health nurses to reflect on their care practice at occupational health services from the perspective of diagnosing and intervening in the alcohol consumption pattern, in the sense of health promotion and prevention of the damage alcohol causes, despite the lack of Brazilian studies on the screening of the alcohol consumption pattern among workers, mainly regarding occupational health nurses’ activities in that context.(8,9) The results demonstrated the high prevalence of hazardous, harmful consumption and probable dependence among male workers with low education levels. The sample revealed hazardous alcohol consumption rates (12.7%) similar to other Brazilian studies, mainly among men, with greater proportions of hazardous consumption and statistical significance for this association, based on various studies.(10-13) An association was found between workers with higher education levels and hazardous alcohol consumption. This association was also found in workers from large companies, but the rates of hazardous consumption were higher in the inferior education group.(6) As regards the occupational profile associated with the hazardous consumption pattern, despite the lack of statistical significance, workers with more than ten years of experience at the university and less than five years in their current sector were Brites RM, Abreu AM associated with the hazardous consumption pattern. The more experience in the company, the greater the emotional exhaustion, the less control on life and the greater the alcohol consumption. The literature reveals that professional satisfaction is related with professional experience, institutional involvement and stability gained, whose characteristics determine the worker’s continuation at an institution. In other words, it was observed that the interviewed workers had been working at the institution for a long time, but only a short time in the sector, supposing limited involvement with the work.(14) As regards the association between the function at the university and the hazardous alcohol consumption pattern, the results showed that this pattern was more frequent among administrative and intermediary support technicians. In these technical functions, the alcohol consumption frequency is higher, as they are characterized as downgraded by society or determinants of rejection, with restricted possibilities of ascent by professional qualification, which can generate mental suffering.(7,14) In this study, 49.4% were abstemious. Similar results were found among public servants at a university in the South of Brazil, with 49.8%, and in the general population, with 48%.(14) Despite the high rate of abstemious people, however, this situation cannot be forgotten or ignored. Surveillance should be constant and a target of intersectoral and health policies, as alcoholic drink commercials are both qualitatively and creatively outstanding. Nevertheless, the percentage of workers who consumed alcohol was higher than at the national level.(10-14) In this context, the percentage of abstemious people could be underestimated with regard to the interviewed workers at the occupational health service as, although the study preserved their anonymity, they were afraid to answer the questions about alcohol consumption, as they were at a medical expertise service. Regarding the consumption of alcohol in number of drinks on a typical day, it was verified that 32.5% of the sample consumed five or more doses on a typical day. The frequency of binge drinking on a typical day among these workers is notewor- thy. In the lowest risk group (AUDIT <8), signs of binge drinking were found in 29.5% of the workers who reported low-risk consumption. Studies have indicated that binge drinking is associated with more and greater physical, social and mental problems than consumption patterns approaching dependence.(14,15) This showed that these workers consumed great quantities of alcohol on a single occasion in the last 12 months, thus consolidating the need for the Occupational Health Service to adopt more effective interventions with these workers, through a health promotion and prevention policy of the problems related to alcohol use and abuse. When analyzing the total number of workers who manifested binge drinking sometimes (monthly, weekly and daily), the gravity of the situation is revealed: 47.2% of the workers consumed six or more doses on a single occasion. The harm caused by high consumption levels of alcoholic beverages is commonly associated with productivity declines and with family violence.(15) In the work organization sphere, increased absenteeism, early retirement and frequent medical leaves, decreased productivity, employee turnover, relationship difficulties among peers and reduced motivation in the company are highlighted.(2-5) One important sign of the problems alcohol consumption causes in this sample was the frequency of binge drinking. These workers admitted they were advised to stop drinking by a friend, relative or health professional: 10.9% of the sample had already been advised to stop drinking. It was observed that, even if the consumers do not perceive their alcohol consumption, they reflect concern with the possibility that this habit will cause harm to themselves or other people. One of the main factors in family violence is alcohol abuse, due to the boldness it produces and the reduction of the ability to judge, facilitating the occurrence of aggressive behaviors, mainly against women and children. The consequences of this violence result in loss of control, denial, minimization and a cycle of progressive increase, followed by contrition and promises of change, affecting the aggressor’s family and professional life.(16) Acta Paul Enferm. 2014; 27(2):93-9. 97 Alcohol consumption pattern among workers and socioeconomic profile There is no doubt as to the need to apply more effective prevention measures in the companies, including investments in better conditions in the work environment. Unfortunately, however, the sociocultural aspects stimulate the addiction and make it difficult for the workers to adhere to the treatment programs.(10-13) Based on the study results, this would by facilitated by this group’s education level, with 55.9% of higher education, which can determine a further understanding, comprehension and impact of the prevention programs on the effects of alcohol abuse. This fact would favor health promotion and disease prevention in the work context, indirectly reducing absenteeism levels.(10-13) The multiprofessional team at the service plays a relevant role in the identification and approach of these workers, whose drinking pattern entails risks or damage to their health.(6) Mainly, as team members, occupational health nurses should be trained to attend to these workers. Therefore, training will be needed for this activity, offering preparation to the other occupational health team members so that everyone is skilled to conduct these workers with a view to reducing the alcohol consumption pattern, using the short intervention based on a screening instrument, in accordance with different authors.(2,4,7-9) The screening of the workers’ consumption pattern has been used at some occupational health services to identify the alcohol consumption pattern, using the AUDIT questionnaire. This tool was used in this study as one of the steps of the short intervention process, mainly in primary care services, highlighting the occupational health services in that context. The use of this strategy facilitates the initial contact and permits objective feedback to the individual, allowing the introduction of short intervention procedures at the service and motivation to change the workers’ behavior, whose consumption pattern is abusive.(2,4,7-9) The role of nurses in the occupational health service is highlighted, in the private and public spheres, with a view to using the AUDIT questionnaire as a short intervention tool, supporting the systematics of nursing care, mainly in the health promotion and alcohol abuse strategies. 98 Acta Paul Enferm. 2014; 27(2):93-9. Conclusion The results showed the high prevalence of hazardous, harmful consumption and probable dependence associated with male workers and low education levels. Collaborations Brites RMR and Abreu AMM contributed to the conception and planning of the project, the data collection, interpretation of the data, writing of the article, relevant critical review of the content and final approval of the version for publication. References 1. World Health Organization (WHO). Global status report on alcohol and health 2011 [Internet]. Genebra: WHO; 2011. [cited 2014 Mar 11]. Available from: http://www.who.int/substance_abuse/publications/ global_alcohol_report/en. 2. World Health Organization (WHO). Involvement of nurses and midwives in screening and brief interventions for hazardous and harmful use of alcohol and other psychoactive substances. A literature review [Internet]. Genebra: WHO; 2010. [cited 2014 Mar 11]. Available from: http://www.who.int/hrh/resources/substances/en. 3. Organización Panamericana de La Salud. Alcohol y atención primaria de la salud. Informaciones clínicas básicas para la identificación y el manejo de riesgos y problemas [Internet]. Washington: OPS, 2008[cited 2014 Mar 11]. Available from: http://www.who.int/substance_abuse/ publications/alcohol_atencion_primaria.pdf. 4. Jomar RT, Paixão LA, Abreu AM. Alcohol Use Disorders Identification Teste (AUDIT) e sua aplicabilidade na atenção primária à saúde. Revista APS. 2012;15(1):113-7. 5. Brasil. Presidência da República. Secretaria Nacional de Políticas sobre Drogas. Relatório brasileiro sobre drogas / Secretaria Nacional de Políticas sobre Drogas; IME USP; organizadores Paulina do Carmo Arruda Vieira Duarte, Vladimir de Andrade Stempliuk e Lúcia Pereira Barroso [Internet]. Brasília, DF: SENAD; 2009. [citado 2014 Mar 11]. Disponível em: http://www.obid.senad.gov.br/portais/OBID/biblioteca/ documentos/Relatorios/328379.pdf. 6. Fontenelle LF. [Alcoholic beverages consumption among workers of a family health strategy center in Vitória, Espírito Santo, Brazil]. Rev Bras Med Fam Com. 2012;7(25): 33-9. Portuguese. 7. Hermansson U, Helander A, Brandt L, Huss A, Rönnberg S. Screening and brief intervention for risky alcohol consumption in the workplace: results of a 1-year randomized controlled study. Alcohol Alcohol. 2010; 45(3): 252-7. 8. Watson H, Godfrey C, Mcfadyen A, Mcarthur K, Stevenson M. Reducing alcohol-related harm in the workplace: a feasibility study of screening and brief interventions for hazardous drinkers [Internet]. Glasgow: Glasgow Caledonian University; 2009 [cited 2014 Mar 11]. Available from: http://alcoholresearchuk.org/downloads/finalReports/AERC_ FinalReport_0063.pdf. Brites RM, Abreu AM 9. Jomar RT, Abreu AM. [Scientific production on alcoholic beverage intake in Brazilian nursing journals] [Internet]. Rev Enferm UERJ. 2011;19(3):491-6. Portuguese. 13. Laranjeira R, Pinsky I, Sanches M, Zaleski M, Caetano R. [Alcohol use patterns among Brazilian adults]. Rev Bras Psiquiatr. 2009;32(3):23141. Portuguese. 10. Bortoluzzi M, Traebert J, Loguercio A, Kehrig R. [Prevalence and alcohol user profile in adult population in a south Brazilian city]. Ciênc Saúde Coletiva. 2010;15(3):679-85. Portuguese. 14. Reisdorfer E, Büchele F, Pires RO, Boing AF. Prevalence and associated factors with alcohol use disorders among adults: a population-based study in southern Brazil. Rev Bras Epidemiol. 2012; 15(3):582-94. 11.Branco AA, Mascarenhas FA, Pena LJ. [Alcoholism as a factor of incapacity to work: prevalence of sickness benefits in Brazil, 2007]. Com Ciência Saúde. 2009;20(2):123-33. Portuguese. 15. Ortiz CM, Marziale MH. Consumo de alcohol en personal administrativo y de servicios de una universidad del Ecuador. Rev Latinoam Enferm. 2010;18(n spe):487-95. 12.Ferreira LN, Sales Z, Casotti CA, Bispo JJ, Braga JA. [Alcohol consumption and associated factors in a city in Northeast Brazil]. Cad Saúde Publica. 2011;27(8):1473-86. Portuguese. 16.Fonseca AM, Galduróz JC, Tondowski CS, Noto AR. Padrões de violência domiciliar associada ao uso de álcool no Brasil. Rev Saúde Pública. 2009;43(5):743-9. Acta Paul Enferm. 2014; 27(2):93-9. 99 Original Article Root cause analysis of falling accidents and medication errors in hospital Análise de causa raiz de acidentes por quedas e erros de medicação em hospital Thalyta Cardoso Alux Teixeira1 Silvia Helena de Bortoli Cassiani2 Keywords Quality of health care; Patient safety; Accidental falls; Medication errors; Risk management; Medication system, hospital Descritores Qualidade da assistência à saúde; Segurança do paciente; Acidentes por quedas; Erros de medicação; Controle de risco; Sistemas de medicação no hospital Submitted January 9, 2014 Accepted March 20, 2014 Corresponding author Thalyta Cardoso Alux Teixeira Av. Comendador Enzo Ferrari, Campinas, SP, Brasil. Zip Code: 13043-900. [email protected] DOI http://dx.doi.org/10.1590/19820194201400019 100 Acta Paul Enferm. 2014; 27(2):100-7. Abstract Objective: To identify fall incidents and medication errors reported in a general private hospital and to introduce the causal factors categories of these incidents. Methods: Cross-sectional and exploratory study based on 62 reported incidents within the period of study. The research instrument was created in order to collect data from notification forms and patients’ medical records. The content validation of the instrument was performed by judges. Two teams were set up to analyze the root cause of incidents and to categorize the causal factors. Results: Within the period of study, 62 incidents were reported, of which 11 were falls and 51 were medication errors. Most of the fall were from own height, and the main medication error types were omission and timing. Out of the 19 analyzed incidents, a total of 118 causal factors were identified, most of which were related to systemic failures, followed by individual and patients failures. Conclusion: Medication errors occur more frequently than fall accidents. The root cause team analyzed 14 medication errors with potential to cause harm and five fall accidents, with 83 and 35 identified causal factors respectively. Resumo Objetivo: Identificar incidentes por queda e erros de medicação notificados em um hospital geral e privado e apresentar as categorias de fatores causais desses incidentes. Métodos: Trata-se de estudo transversal e exploratório realizado com 62 incidentes notificados no período de estudo. O instrumento de pesquisa foi elaborado para coletar dados dos formulários de notificação e dos prontuários dos pacientes. A validação de conteúdo do instrumento foi realizada por juízes. Foram constituídas duas equipes para análise da causa raiz dos incidentes e categorização dos fatores causais. Resultados: No período de estudo foram notificados 62 incidentes, sendo 11 quedas e 51 erros de medicação. A maior parte das quedas foi da própria altura, e os principais tipos de erros de medicação foram omissão e horário. Dos 19 incidentes analisados, um total de 118 fatores causais foram identificados, sendo a maioria relacionada às falhas sistêmicas, seguidas por falhas do indivíduo e do paciente. Conclusão: Erros de medicação ocorrem com maior frequência do que acidentes por quedas. A equipe de causa raiz analisou 14 erros de medicação com potencial para causar danos e cinco acidentes por queda, sendo identificados 83 e 35 fatores causais, respectivamente. Universidade Paulista, Campinas, SP, Brazil. Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil. Conflicts of interest: there are no conflicts of interest to declare. 1 2 Teixeira TC, Cassiani SH Introduction Currently, most institutions have been seeking to achieve quality of care and safety for patients in health services, in order to provide risk-free care. There are many definitions of quality, used both in relation to health care and health systems and in other spheres of activity. In technical use, quality can have two meanings: the characteristics of a product or service that affects one’s capacity to meet explicit or implicit needs, and a product or service with no deficiency.(1) According to the World Health Organization, a quality health service is the one that organizes its resources in the most effective way to meet the actual needs, safely, without any waste and according to high standards and respect for human rights.(2) For this end, it is necessary to implement safe practices in this context in order to prevent their occurrence, such as training, the use of updated protocols by the multidisciplinary team, the presence of safety committees for patients, the notification of incidents by the professionals, and subsequently, analyses of these incidents that identify the causes, among other strategies. It is observed that incidents related to the patient’s safety are events or circumstances that might have resulted, or resulted in unnecessary harm to the patient. An incident can be a reported circumstance, a near mistake, an incident with no harm to the patient or an incident with harm, that is, an adverse outcome, whereas the patient’s safety involves the reduction of risks and unnecessary harm related to the health care to a minimum extent.(3) The expression “patient safety” refers to the factors that lead the institutions to make use of the safety culture, considering the best practices. This expression must be seen as a result, that is, the work that is performed in a system in which protocols are updated and based on scientific literature, in which technology is implemented in order to improve the processes and training is carried out for the whole healthcare staff, providing more safety and fewer risks to patients. It often involves the promotion of a safe environment, exploring the possibilities of occurrence of incidents in health, such as falls, medication errors, and infections, among others. Many incidents related to patient safety, such as falls and medication errors, are often studied and presented in national and international studies, as they might cause harm to patients. In the United States, falls are the most common causes of non-lethal injuries to people over 65 in neighborhoods. Out of the individuals living in neighborhoods who are over 65, 32% fall every year, and this happens more frequently to women.(4) Regarding medication errors, although it is known that the adequate use of medicine can have positive effects on individuals, improper use may occur, resulting in undesired and even harmful effects for the patients. A study identified 2,181 medication errors in 54,169 cases, and the implementation of new technologies in the distribution process has increased safety, especially with electronic prescription, which allows a decrease in this type of errors.(5) As for the preparation and administration of drugs by the nursing staff, the occurrence of 550 events was observed, most of which were related to the absence of checking of at least “five rights” in the drug administration, to drugs not administered and to inaccurate notes.(6) When quality levels show significant loss, actions must be taken in order to correct them, which means improvement for the institution. To ensure this, the analysis of incidents related to patient safety must be carried out, based on quality methodologies. As the root cause analysis is a methodology that is easy to apply, which does not require many resources and promotes a critical and thorough analysis of the incidents, it was used in this study to analyze falls that caused harm and medication errors with potential to cause harm, that is, that involved the administration of potentially dangerous drugs (PDD) and anti-infective agents. The root cause analysis analyzes incidents in a reactive manner and can introduce actions that reduce them. It is a systematic process in which the factors that contribute to the occurrence of an incident are identified by means of reconstruction of this logic sequence and the question Acta Paul Enferm. 2014; 27(2):100-7. 101 Root cause analysis of falling accidents and medication errors in hospital “why” is asked until the underlying causes have been found.(3,7) After the identification of incidents by means of voluntary reports and notification, it is necessary to set up a root cause analysis team, which is multidisciplinary, in order to contribute with different points of view about the analyzed incident and to identify different causal factors. Also, a person with knowledge of this analysis is essential, so they can act as a facilitator. This analysis favors the assessment of the studied system, the identification of errors in the processes and the conclusion that systemic failures are often prevalent in health institutions when compared to individual failures. Furthermore, the root cause analysis allows investigating any kind of incident related to health care and that is why it was chosen for this study. Hence, we made an adjustment of the methodologies of root cause analysis proposed by Taylor-Adams and Charles Vincent, in the London Protocol, by Seeking Out the Underlying Root Causes of Events (SOURCE) and by Andersen and Fagerhaugh, to analyze the falls and medication errors that caused harm or had potential to do so.(8) The objectives of this study were to identify fall incidents and medication errors reported in a general private hospital and introduce the causal factors categories of these incidents. Methods A cross-sectional and exploratory study was carried out between January and March of 2012, in which the nature of incidents related to patient safety were investigated, as well as the way they manifest and other possible factors such as their cause, rather than the simple observation and description. The study was carried out in a private general hospital, located in the countryside of the state of São Paulo, southern Brazil. This hospital is certified by the Commitment to Hospital Quality Program, which fosters self-assessment and includes an educational component that encourages changes of attitude and behavior. 102 Acta Paul Enferm. 2014; 27(2):100-7. The hospital had a total of 158 beds and, in March 2011, the electronic prescription was implemented in the adult, cardiac and pediatric ICUs. Drug distribution was performed through individual doses, by five pharmacists in the whole institution. The nursing staff was composed of nursing technicians and nurses. There were forms for notification of incidents related to patient safety, identified by the nursing staff. The studied universe was composed by 62 incidents related to patient safety, out of which 11 were falls and 51 were medication errors that were reported in 44 forms filled out by the nursing staff. Out of these, five falls and 14 medication errors that might have caused harm or had potential to do so were identified and submitted to the root cause analysis. The research instrument was created in order to collect data from notification forms and patients’ medical records. To validate the content, the instrument was submitted to five experts, all of them nursing masters or PhDs with knowledge of the quality and patient safety topics. For data collection, notification forms that are kept by the coordinators of each area were used, and these data, as well as those contained in the medical records, were transcribed into the data collection instrument, by three auditors. The researcher identified the incidents related to patient safety that caused harm, regarding falls, or that presented potential risks in the case of medication errors, and submitted them to the root cause analysis methodology. Hence, five falls that caused harm to patients and 14 medication errors related to potentially dangerous drugs and anti-infective agents were selected for analysis. Two root cause analysis teams were set up, one to analyze falls and the other to analyze medication errors, and a total of ten meetings were held. The team for root cause analysis of falls was made up of two treating nurses, two coordinating nurses, a nurse from the hospital infection control service, and a pharmacist. The other root cause analysis team was made up of two attending nurses, two coordinating Teixeira TC, Cassiani SH nurses, a nurse from the hospital infection control service, an auditor nurse, and a pharmacist. In this team, the auditor nurse and one of the attending nurses attended only the first meeting, due to their activities within the institution or because of holiday periods. Medical professionals were invited to participate in the study but they stated that, due to their work routine, they would not be able to attend the meetings. The development of the study complied with national and international ethical guidelines for studies involving human beings. Results A total of 62 incidents related to falls and medication errors were reported between January and March of 2012 in the aforementioned institution, where 11 (17.7%) were falls and 51 (82.3%) were medication errors. Out of these incidents, nine (17.7%) occurred in January, 15 (33.9%) in February and 27 (48.4%) in March. Most medication errors (43.5%) occurred in March, whereas most falls (9.7%) happened in February. Regarding the period of occurrence, eight incidents (12.9%) occurred during the morning, 22 (35.5%) in the afternoon and 29 (46.8%) during the evening. For three incidents related to medication errors (4.8%), it was not possible to identify the period of occurrence, as the notification form did not contain this piece of information and there was no report of the incident in the patient’s medical record. Most incidents (42, or 67.8%) occurred in the hospitalization ward, followed by the maternity ward (10, or 16.1%), neonatal ICU (4, or 6.5%), cardiac ICU (1, or 1.6%), and no incidents were reported in the pediatric ICU. Regarding falls, most of them were from own height (5, or 45.5%), followed by bed height (3, 27.3%), toilet (2, or 18.2%) and rest chair (1, or 9%). Regarding medication errors, a total of 51 incidents related to drug administration were iden- tified in 33 notification forms, where 54 types of error occurred. In that sense, omission errors (17, or 31.5%), timing errors (12, or 22.2%), administration technique errors (8, or 14.8%), extra doses errors (4, or 7.4%), non-authorized drug errors (4, or 7.4%) and route of administration errors (1, or 1.9%) were reported. After the identification of patients, the five falls that caused harm to patients were submitted to root cause analysis. Therefore, there was a total of 35 causal factors, out of which nine (25.7%) were related to the ‘patient’ category, eight (22.9%) to the ‘team’ category, six (17.1%) to the ‘environment’ category, five (14.3%) to the ‘task’ category, four (11.4%) to the ‘individual’ category and three (8.6%) to the ‘management’ category, as shown in table 1. Table 1. Categories of causal factors related to falls Categories of causal factors Causal factors n(%) Pacient Medical diagnosis and symptoms such as dizziness, history of falls, low or advanced age (5 years-old or under, and 60 years-old or over), immediate postoperative, anesthesia effect, non-compliance with guidance. 9(25.7) Team Verbal communication failure in the nursing staff to inform about the previous fall; Verbal communication failure between the nursing staff and the reception regarding the release of beds; Verbal communication failure between the nursing staff and the patient with risk of falling; Lack of preventive care notes about falls in the nursing prescription. Bad supervision of staff to assess the risk of falling and the type of bed/cradle that presented greater risk for the patient. 8(22.9) Environment High bed, small number of cradles, absence of a bell next to the bedside table, time close to change of shift, time of greater work demand. 6(17.1) Task Absence of protocol for prevention of falls. 5(14.3) Individual Leaving the bars lowered and place pads between bars; inexperience; lack of examination of patients in the immediate post-operative period by the nurse at admission. 4(11.4) Management Small number of professionals 3(8.6) Total 35(100) Acta Paul Enferm. 2014; 27(2):100-7. 103 Root cause analysis of falling accidents and medication errors in hospital Likewise, the root cause analysis team analyzed 14 medication errors with potential to cause harm and identified a total of 83 causal factors. As for the categories of causal factors related to medication errors, 27 (32.6%) were related to management, 18 (21.7%) to the individual, 16 (19.3%) to the team, 10 (12%) to the environment, eight (9.6%) to the task, and four (4.8%) to the patient. Table 2 shows this distribution. Table 2. Causes of medication errors regarding the causal factors categories Causal factors categories Causes n(%) Management Absence of a safety committee for the patient, absence of electronic prescription in the service, absence of a predetermined schedule for drug prescription, policy for an increased hiring of nurses and pharmacists, small number of nursing and pharmacy professionals, lack of training of professionals about the topic. 27(32.6) Individual Professionals’ lack of attention, no check of any of the “five rights” or the identification bracelet, professionals’ lack of knowledge of the protocol, dispensation without following the pharmacy protocol, preparation and administration of drugs by the professional to several patients at the same time, no observation of the drugs infused to the patient at the beginning of the shift. 18(21.7) Team Bad or no supervision by the nurse and pharmacist and inadequate search for help by nursing and pharmacy technicians, lack of congruency among the members of nursing staff, illegibility of the medical prescription, inadequate communication between physician and nurses and between members of the nursing staff. 16(19.3) Environment Excessive workload, inadequate combination of skills between pharmacy and nursing, absence of a strategic place to store current prescriptions in the services, interruptions. 10(12.0) Task Absence of protocol in the drug administration that focuses on the patient’s safety, absence of control of the number of prescriptions per patient. 8(9.6) Pacient Complexity and severity of the patient. 4(4.8) Total 83(100) After the identification of the causal factors and by adopting the best practices, the root cause analysis teams identified the recommendations in order to avoid these incidents within the institution. 104 Acta Paul Enferm. 2014; 27(2):100-7. Discussion This study has limitations due to the method adopted, that is, a cross-sectional study with a retrospective analysis of data that does not establish cause and effect relations, which instead identifies patients and allows the understanding of the occurrences.(9) The root cause analysis method allows achieving a deep analysis of the incidents that occur, by identifying the different causes that contributed to a specific incident, and to suggest ways to prevent recurrence, which partly overcomes these limitations. The nursing staff is part of this context, where medication errors and falls occur, and in Brazil, the cause for incidents related to patient safety very often falls upon this staff, although it is known that, in addition to individual failures, badly made processes and other failures such as environmental or structural ones also contribute to it. Only after the investigation and analysis of incidents, recommendations can be implemented in order to ensure a safe, risk-free working environment and based on best practices, which will consequently result in improvements of care given to patients, including nursing care. Nevertheless, the fact is that incidents must be reported, notified and analyzed, not only by the nursing staff, but by the whole multidisciplinary staff, so as to find the causes for these problems. In this study, a greater number of notifications was found regarding medication errors (51, or 82.3%) when comparing to falls (11, or 17.7%) occurred within the institution. A study that analyzed the report of incidents related to patient safety reported in the American health system showed that 9% of patients had at least a reported incident, of which 29% were medication errors and 14% were falls.(10) In contrast, a Brazilian study identified 229 incidents related to patient safety in a hospital, where 57.6% were related to the removal of the nasogastric tube, 16.6% to falls and 14.8% to drug administration errors.(11) Teixeira TC, Cassiani SH Thus, both the results of this study and the literature had a higher incidence of medication errors than falls, due to the high number of drugs prescribed and administered on a daily basis to hospitalized patients. Most incidents related to falls and medication errors occurred in the hospitalization wards (42, or 67.8%), as this service has a greater number of beds than other assessed services. Also, there was no notification of this type of incident in the pediatric ICU during that period of three months. Managers and administrators must encourage professionals to report the occurrence of incidents related to patient safety by focusing on the safety culture rather than focusing on punishment, as fear of punishment often results in the absence of notification of incidents. The success of a notification system depends on the break of some taboos associated with it, so cultural changes must be implemented in order to make notifications a voluntary action. Regarding the type of fall, most were from own height (5, or 45.5%) and from bed (3, or 27.3%) and they occurred mainly when the patient tried to leave the bed or when they left it for physiological reasons. Hospitalized patients are often more fragile and need help from the nursing staff when they have to complete daily routine tasks such as getting out of bed or bathing. That is why health institutions, along with their nursing staff, must focus on their participation in these activities and give appropriate guidance on the risks the patient might run, such as falls, and for that, it is necessary to have an adequate quantity of nursing professionals to meet this demand, who should be properly trained to prevent these falls. In the study, 54 types of medication errors were found, and most of them were omission errors (17, or 31.5%), timing errors (12, or 22.2%), administration technique errors (8, or 14.8%), and dosage errors (8, or 14.8%). An American study that evaluated an error notification system found that 631 errors were report- ed, where omission errors (32%) and dosage errors (21%) were the most common.(12) In contrast, a Brazilian study found that dosage errors (24.3%) and timing errors (22.9%) happened more frequently in a teaching hospital.(13) In our study, the causes were categorized according to causal factors and by applying the root cause analysis methodology. Therefore, regarding falls and medication errors, most causal factors found were systemic failures, followed by individual and patient’s failures, confirming that incidents occur mainly because of systemic failures rather than individual ones. The psychologist Reason suggests two ways to approach the incident: the individual approach and the systemic approach. The first includes the individual unsafe acts from first line professionals, which are mistakes and violation of procedures, starting from a non-standard mental process such as: forgetfulness, lack of attention, carelessness, poor motivation, negligence and imprudence. The second considers that incidents occur due to a badly shaped system. In this system, active failures and latent failures lead to the occurrence of incidents. Active failures are those that occur in the front line, and their effects are noticeable almost immediately; their forms are oversights, slippages and failures in the process. Latent failures remain “asleep” in this system and are related to organizational influences, unsafe supervision and predisposition to unsafe acts.(14) Another important aspect of the study was the finding that a great part of causal factors of falls was affected by the absence of protocol of fall prevention within the studied institution. The institutional protocol oriented towards fall prevention has a key role in health institutions, in order to avoid incidents related to patient safety. From the moment it is created, focusing on best practices, a risk assessment scale is added to the patient’s evaluation, on a daily basis, in order to identify the risk, and adequate preventive measures can be taken by the members of the health staff.(15) Acta Paul Enferm. 2014; 27(2):100-7. 105 Root cause analysis of falling accidents and medication errors in hospital To implement the protocol, a program must be created in order to do it efficiently, seeking the decrease of falls in the institution, and this program must be evaluated periodically so as to find out whether it is being performed adequately.(15) Regarding the causal factors of medication errors, several factors affected the occurrences, like the absence of a patient safety committee, electronic prescription available only in a few services, individual failures, among others. When medication errors occur, multifactorial causes in a badly shaped system affect their occurrence, as well as manual prescriptions, lack of bar codes, stress, fatigue, lack of attention and lack of ability.(16,17) Currently, it is recommended that health institutions organize a patient safety committee, as it is essential for the development of a safety culture where the main focus is not to punish when an incident is detected, and to promote the implementation of recommendations oriented toward best practices, in order to contribute to patient safety and to consequently reduce the number of accidents related to that. In that sense, institutions must focus on this safety culture, to encourage the involvement of professionals into patient safety, aiming to identify, notify and analyze incidents, and consequently improve the quality of care. Conclusion The application of the root cause analysis methodology allowed to find the causes and categorize them according to causal factors. Therefore, most causal factors found regarding falls and medication errors were systemic failures, followed by individual and patient’s failures, confirming that incidents occur mainly because of systemic failures rather than individual ones. Collaboration Teixeira TCA contributed to the conception of the project, to the execution of the research, the writing of the article and the final approval of 106 Acta Paul Enferm. 2014; 27(2):100-7. the version, and Cassiani SHB contributed to the conception of the study and to the critical review of the content. References 1. JM Juran, AB Godfrey. Juran`s quality handbook [Internet]. 1998 [cited 2013 Dec 18]. Available from: http://www.pqm-online.com/assets/ files/lib/juran.pdf. 2. Organização Mundial de Saúde. Relatório Mundial de Saúde 2008: Cuidados de saúde primários: agora mais que nunca [Internet]. 2008 [citado 2009 jul. 12] Disponível em: http:www.who.int/whr/2008/en/ index.html. 3. World Health Organization. Conceptual framework for the international classification for patient safety. 2009 [cited 2011 May 16]. Available from: http: www.who.int/entity/patientsafety/taxonomy/icps_full_ report.pdf. 4. Centers for Disease Control and Prevention. WISQARS injury mortality reports 1999 - 2004. 2006 [cied 2011 Sep 1]. Available from: http:// webappa.cdc.gov/sasweb/ncipc/leadcaus10.html. 5. Álvarez-Díaz AM, Silveira ED, Menéndez-Conde CP, Recuenco RP, Silanes EG, Pérez JS, et al. New technologies applied to the medicationdispensing process, error analysis and contributing factors. Farm Hosp. 2012;34(2):59-67. 6. Beccaria LM, Pereira RA, Contrin LM, Lobo SM, Trajano DH. Eventos adversos na assistência de enfermagem em uma unidade de terapia intensiva. Rev Bras Ter Intensiva. 2009;21(3):276-82. 7. Fasset WE. Key Performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills. Am J Pharm Educ. 2011;75(8):164. 8. Taylor-Adams S, Vincent C. Systems analysis of clinical incidents: The London protocol. Clin Risk. 2004;10(6):1-21. 9. Ferner RE. The epidemiology of medication erros. Br J Clin Pharmacol. 2009;67(6):614-20. 10. Nuckols TK, Bell DS, Liu H, Paddock SM, Hilborne LH. Rates and types of events reported to established incidente reporting systems in two US hospitals. Qual Saf Health Care. 2007;16:164-68. 11.Nascimento CC, Toffoletto MC, Gonçalves LA, Freitas WG, Padilha KG. Indicadores de resultados da assistência: Análise dos eventos adversos durante a internação hospitalar. Rev Latinoam Enferm. 2008;16(4):746-51. 12.Pierson S, Hansen R; Greene S, Williams C, Akers R, Jonsson M, Carey T. Preventing medication errors in long-term care: results and evaluation of a large scale web-based error reporting system. Qual Saf Health Care. 2007;16:297-302. 13. Teixeira TCA, Cassiani SHB. Análise de causa raiz: avaliação de erros de medicação em um hospital universitário. Rev Esc Enferm USP. 2010;44(1):139-46. 14. Sunol R, Vallejo P, Thompson A, Lombarts MJMH, Shaw CD; Klazinga N. Impact of quality strategies on hospital outputs. Qual Saf Health Care. 2009;18(Suppl-1):i62–i68. 15.Lee A, Mills PD, Watts BV. Using root cause analysis to reduce falls with injury in the psychiatric unit. Gen Hosp Psychiatry. 2012; 34:30411.21 Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes Teixeira TC, Cassiani SH Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006; 6: 44. 16. Tully MP, Ashcroft DM, Dornan T, Lewis PJ, Taylor D, Wass V. The Causes of and factors associated with prescribing errors in hospital inpatients: a systematic review. Drug Safety. 2009; 32(10):819-36. 17.Hartel M, Staub L, Röder C, Eggli S. High incidence of medication documentation errors in a Swiss university hospital due to the handwritten prescription process. BMC Health Serv Res. 2011. 11(1): 199. Acta Paul Enferm. 2014; 27(2):100-7. 107 Original Article Interpersonal Communication Competence Scale: Brazilian translation, validation and cultural adaptation Validação e adaptação cultural para o português da Interpersonal Communication Competence Scale Ana Cláudia Puggina1,3 Maria Júlia Paes da Silva2 Keywords Communication; Validation studies; Nursing research, Nursing, practical; Scales Descritores Comunicação; Estudos de validação; Pesquisa de enfermagem; Enfermagem prática; Escalas Submitted December 13, 2013 Accepted March 18, 2014 Abstract Objective: To validate and culturally adapt the Interpersonal Communication Competence Scale to Brazilian Portuguese, bringing about a new tool that can be used by healthcare professionals. Methods: A descriptive and cross-sectional validation study using a quantitative and qualitative approach. Factor analysis, principal components analysis with flag 40 and an evaluation of internal correlation through Cronbach’s alpha were performed. Results: The final version of the scale was named Escala de Competência em Comunicação Interpessoal and consisted of 17 items and five domains. The Cronbach’s alpha across the five domains was 0.71 and between the items it was 0.82. Conclusion: The scale was validated and adapted in relation to the content and the construct with a good correlation index between the domains and items. Resumo Objetivo: Validar e adaptar culturalmente a Interpersonal Communication Competence Scale para o português, trazendo uma nova ferramenta que possa ser utilizada pelos profissionais da área da saúde. Métodos: Estudo de validação descritivo e transversal com abordagem quanti-qualitativa. Foi realizada análise fatorial, análise de componentes principais com flag de 40 e avaliação da correlação interna por meio do Alpha de Cronbach. Resultados: A versão final da escala foi nomeada Escala de Competência em Comunicação Interpessoal e compôs-se por 17 itens e 5 domínios. O Alpha de Cronbach entre os cinco domínios foi de 0,71 e entre os itens foi de 0,82. Conclusão: A escala foi validada e adaptada em relação ao conteúdo e ao constructo com um bom índice de correlação entre os domínios e os itens. Corresponding author Ana Cláudia Puggina Tereza Cristina square, 88, Guarulhos, SP, Brazil. Zip Code: 07023-070 [email protected] Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brazil. Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, Brazil. 3 Universidade de Guarulhos, Guarulhos, SP, Brazil. Conflicts of interest: there are no conflicts of interest to declare. 1 DOI http://dx.doi.org/10.1590/19820194201400020 108 Acta Paul Enferm. 2014; 27(2):108-14. 2 Puggina AC, Silva MJ Introduction The Interpersonal Communication Competence Scale is a self-administered instrument that assesses ten dimensions of interpersonal communication competence (self-disclosure, empathy, social relaxation, assertiveness, altercentrism, interaction management, expressiveness, supportiveness, immediacy, and environmental control).(1) Competence is the ability that an individual has to express a value judgment about something that is well known; the sum total of knowledge or skills. Interpersonal competence skills are important for effective communication and can be improved through instruction and changed over time.(1) The analysis of internal reliability of the scale with 60 items obtained a total alpha coefficient of 0.77 and items with low correlations were removed. The scale was reduced to 30 items with a total alpha coefficient of 0.86 applied to 247 students. Items must be applied randomly and renumbered without the names of the skills. The scale used in the original was a five-point Likert scale.(1) The scale has 24 positive and six negative (reverse code) items. The reverse codes need to be recoded before the final score. Thus, for example, in an item with a reverse code, a rating of five would receive a rating of one on the final score (4=2, 3=3, 2=4, 1=5), and so on. The total score ranges from 30 to 150, with an average of 90 points.(1) Considering the need for assessment tools in interpersonal communication and the limited availability of these instruments in the Portuguese language, this study aimed to validate and culturally adapt the Interpersonal Communication Competence Scale to Brazilian Portuguese, bringing about a new tool that can be used by nursing professionals. Methods This is a descriptive and cross-sectional validation study developed in two phases: the first phase included translating the instrument, which was performed by English language and communication experts, who also formed the panel of judges, and a qualitative evaluation of the pre-test version of the scale, performed by 13 professors; in the second phase, 177 undergraduate nursing students quantitatively answered the pre-final test of the scale. Cultural adaptation was a process that comprised five internationally recommended stages, in which the evaluation of semantic, idiomatic, cultural and conceptual equivalences between the original and translated versions was performed, searching for content validity and the construct of the instrument.(2) In the first stage, two independent bilingual translators, one who knew about the scale subject and another who did not know translated the scale, producing translations T1 and T2. In the second stage, a third bilingual professional, knowledgeable about Brazilian culture and proficient in Brazilian Portuguese as well as in English, composed a final version (synthesis T12) of the two translations working with the original instrument and the two initial translations. In the third stage, the participating translators had been born and educated in the country of the original scale, i.e., they were both North American. They had no access to the original instrument at this point, and only worked with the T12 synthesis to develop the back-translations (BT1 and BT2). In the fourth stage, a panel of judges composed of nine bilingual members (three translators, one linguist, one undergraduate student and four specialists in communication) reviewed all the versions. The author of the scale made important contributions based on the back-translations. In the panel of judges, members received all versions of the scale and were asked to point out any identified issues and propose solutions. They also received the instructions for the application of the scale, as well as guidelines for calculating the score. In this stage, the judges evaluated the semantic, idiomatic, conceptual and cultural equivalences of the instrument and proposed the pre-test version. In the fifth stage, the pre-test version was evaluated qualitatively and the pre-final version was evaluated quantitatively. In the pretest, 13 Acta Paul Enferm. 2014; 27(2):108-14. 109 Interpersonal Communication Competence Scale: Brazilian translation, validation and cultural adaptation professors answered the scale items and were then interviewed to determine whether there was any difficulty in understanding the items. The interviews were conducted using the following guiding questions: (1) In general, did you have any difficulty in understanding and completing the items in the scale?; (2) Could you point out and justify which items you had more difficulty with or had to read more than once to understand what was being proposed?; and (3) What did you think of the scale applied? The qualitative data were transcribed and analyzed individually in order to improve the understanding of the instrument. The pre-final version was drafted. The calculation of the minimum sample for validation of the instrument was obtained following the recommended criterion of five subjects per item from the original scale being validated, i.e., it should have at least 150 participants.(3) To confirm the domains of the pre-final version, a confirmatory factor analysis was performed, with the selection criterion for the amount of domains being the method of eigenvalue > 1, and the selection of variables was the flag 40. As the fields were not confirmed, a new selection of variables with a study of the correlation by Cronbach’s Alpha (α) and by the method of principal component analysis with a flag 40 was performed. Next, the selected variables were studied again by comparative factorial analysis with determination of the amount of domains using the same method (eigenvalue) and of variables by flag 40, and internal consistency through α. The study development followed the national and international standards of ethics in human research. ing students’ graduation studies, 33.90% (n=60) of students were attending the third year, 27.12% (n=48) the first year, 23.16% (n=41) the second year and 15.82% (n=28) were in their fourth year of studies. In the construct validation of the instrument, the α of the 30 items of the scale was 0.80; however, in the factor analysis, the domains were not confirmed from the original scale and four items were eliminated due to low correlation; even so, the α between the domains was 0.64. Therefore, the analysis was performed considering the principal components with flag 40. Accordingly, 13 items were deleted. A new factor analysis of the remaining 17 items revealed 5 domains with an α of 0.71 between them and an α of 0.82 between the items. For the 19 missing data in the instrument, the imputation method of missing data was assumed for the greatest absolute frequency of each question between the possible responses. The final version of the scale was named Escala de Competência em Comunicação Interpessoal and consisted of 17 items and five domains. The α for each domain and their respective items are presented in table 1. Considering the α in each domain, we do not recommend the use of domains as subscales. Table 1. Domains, items and Cronbach’s Alpha Domains 110 Acta Paul Enferm. 2014; 27(2):108-14. α Environmental control It is difficult to find the right words to express myself. I accomplish my communication goals. I can persuade others to my position. I express myself well verbally.. 0.71 Self-disclosure Others would describe me as warm. I reveal how I feel to others. I tell people when I feel close to them. Other people think that I understand them. 0.69 Assertiveness When I’ve been wronged, I confront the person who wronged me. I take charge of conversations I’m in by negotiating what topics we talk about. I have trouble standing up for myself. I stand up for my rights. 0.68 Interaction management I let others know that I understand what they say. In conversations with friends, I perceive not only what they say, but also what they do not say 0.59 Immediacy I allow friends to see who I really am. My friends truly believe that I care about them. I try to look others in the eye when I speak with them. 0.53 Results Regarding the convenience sample of the 177 undergraduate nursing students, the mean age was 21.51 (sd ± 3.59) years, and the majority of participants were female (n=164, 92.66%), single (n=173, 97.74%) and had never taken a communication course (n=165, 93.22%). As to the year of the nurs- Items (α) Cronbach’s Alpha Puggina AC, Silva MJ Discussion The purpose of the validated scale is to assess competence in interpersonal communication. Competence in interpersonal communication is understood as an ability or skill that an individual has in being able to exchange information between two or more people, expressing themselves and interpreting other’s communication codes, which may be verbal or non-verbal. Interpersonal competence can be defined as the ability to relate effectively with others, as appropriate to the needs of each one and the requirements of the situation. It is a process that achieves the goal of communicators, it assumes a basic knowledge of communication, verbal and non-verbal awareness in interactions, clarity and objectivity, as well as promoting self-knowledge.(3) An individual’s interpersonal communication skills can be influenced by the environment and situation in which the interaction occurs, as well as the individual’s ability to demonstrate his or her feelings, be proactive, give feedback and be available in the relationship. The Environmental Control domain demonstrates the ability of the person in being suited to the environment to achieve their goals. If this suitability exists, the individual is able to express himself/herself more appropriately and persuade others finding the words and more appropriate behavior in that environment and situation. This dimension implicitly shows the influence of space and environment in the individuals’expression, perception and persuasion of individuals. The spaces are constructed by individuals, and the individuals are shaped by the space and environment around them, i.e., the better the adaptability of the individual to an environment, the better and faster this individual is able to communicate effectively.(4) The Self-Disclosure domain presents a person’s ability to demonstrate their thoughts, ideas and feelings through communication. Only through self-disclosure can interpersonal relationships (not just “contacts”) be established, and this should be appropriate for the person and the situation. Behaviors, such as positive nodding, direct and frequent eye-contact, pushing the chest out, touching when appropriate, besides correct and empathetic words, showing acceptance, affection, closeness and trust, as well as the feelings of the individual in the interaction.(4-6) The Assertiveness domain involves the proactive ability to stand for their rights without denying the rights of others, demonstrating security, decision and firmness in attitudes and words. A proactive person thinks and acts in advance defending his or her view in arguments, facts and reasons. Being assertive also involves the way people interpret events in their lives, attributing life events to themselves could facilitate assertive behavior. The Interaction Management domain involves the issue of providing feedback in a bidirectional manner, both in terms of demonstrating comprehension and in relation to perceiving what others feel through non-verbal communication. Interpersonal relationships are dynamic and bidirectional, with individuals constantly interacting by giving and receiving feedback. Feedback is the information that the sender obtains from the receiver ‘s reaction to their message, and it is used to evaluate the results of the transmission. If the person is attentive to the feedback of others, they will be able to understand what the other person is feeling, and to adequately demonstrate their own feelings. Realizing what people feel without them saying constitutes an important communication skill, because people rarely use words to tell us exactly how they feel. The ability to capture these subtle communications relies on basic skills, primarily self perception and self-control.(7) The Immediacy domain indicates that people who are available can demonstrate to others that they are accessible and open to interpersonal communication. To deepen a relationship, a certain degree of willingness on both sides is necessary, as there is a need for exposure as well as perception of and attention to others. In this dimension, the importance of looking at the process of communication appears. To show oneself as available and paying attention, the indiActa Paul Enferm. 2014; 27(2):108-14. 111 Interpersonal Communication Competence Scale: Brazilian translation, validation and cultural adaptation vidual needs, at least, to look at the other person. Looking can be considered a person’s first sign of being interested.(4) The measurement scale that should be used is the same as the original scale. To obtain the total score, the items “I have trouble defending myself ” and “It’s hard to find the right words to express myself ” are reverse coded and need to be recoded. The total score ranges from 17 to 35. The higher the score, the higher the skill in interpersonal communication. Items must be randomly applied. The panel of judges made a general consideration of the difficulty of thinking about the competence in interpersonal communication, without a specific context; therefore, it is suggested that the research participant think of a situation of interaction when answering the questionnaire. When collecting data with students, they were asked to focus on the interaction between themselves in the classroom environment. The scale can be used to analyze competence in interpersonal communication in different interactions and situations, such as between classmates, between co-workers, between family members, between teacher and student, and between professional and patient. Interpersonal communication is a complex issue and difficult to assess, and there are few instruments that have been validated and adapted to Brazilian culture.(8-10) Furthermore, there are a number of limitations in instruments that aim at evaluating the communication; due to their not offering an exhaustive review of the communicative aspects as well as to their not aiming at evaluating the factors that can directly or indirectly influence interpersonal communication, such as cognitive, and attention deficits, impaired visual and spatial perception, as well as memory.(10) However, having a direct and objective instrument for assessing interpersonal communication in different contexts may indicate critical points in relationships. Validity can be understood as the degree to which instruments measure what they should be measuring, i.e., the results of a measurement cor- 112 Acta Paul Enferm. 2014; 27(2):108-14. respond to the true state of the phenomenon being measured. The validity of an instrument can be obtained at three levels of evidence: validity of content, construct and criterion.(11) Content validity refers to the degree to which an instrument reflects a specific content domain; construct validity refers to how the measurement is related internally in a consistent and reliable manner; criterion validity refers to the degree to which the instrument, compared to other external criteria, measures the same concept.(11) In this study, content validity was obtained by comparing the translations and back-translations, as well as with the consensus of the panel of judges. Construct validity was obtained using the α, factor analysis and principal component analysis, which is probably considered the most important stage from the scientific point of view. Criterion validity was not possible to be obtained due to the lack of instruments that measure the studied variable. Factor Analysis and Principal Component Analysis are statistical procedures that have been widely used in the preparation and validation of psychological instruments, and can be conceptualized as statistical techniques aimed at representing a multivariate random process through the creation of new variables, derived from the original variables, in fewer number and which best represent a group.(12,13) Factor analysis of the Escala de Competência em Comunicação Interpessoal has not confirmed the areas proposed in the original scale, probably because the domains of the original scale were produced by a semantic and subjective approach and not by statistical methods. The α, measures the covariance degree of a number of items and ranges from 0 to 1, the higher the score, the higher the reliability of the instrument. Acceptable reliability is assigned to values minimum value ≥0.7. An instrument’s reliability refers to the degree to which it produces consistent and coherent results from the scores obtained. To ensure reliability, the number of items on the scale was reduced from 30 to 17, with a good correlation index (α =0.71) among the five domains. Despite this large reduction of items, because of the Puggina AC, Silva MJ low initial correlation between the domains, the validated scale meets the basic requirements for competent interpersonal communication skills and addresses skills related to both the expression and perception of communication signals in relationships. The Escala de Competência em Comunicação Interpessoal can be used to assess competence in interpersonal communication as well as to strengthen these communication skills in groups or individuals, as they can be improved through education and modified over time. Furthermore, this instrument can be used to improve understanding of the communication process. Interpersonal communication is complex and this instrument may be important in different situations and provide guidelines for individual or group interventions with the aim of improving relationships and well-being in that context, as well as reflecting on the theme from an educational perspective. Nevertheless, to assess interpersonal communication as a whole, using different tools and techniques may be necessary, such as observing interactions, group dynamics, recording and interpreting nonverbal communication etc. Conclusion The Escala de Competência em Comunicação Interpessoal was validated and adapted in relation to the content and the construct with a good correlation index between the domains and items. Acknowledgments The authors thank the professors Ana Lúcia Sesso de Cerqueira Cesar, Eliana Mara Braga, Eliseth Ribeiro Leão de Andrade Silva, Ligia Fahl Fonseca, Michael Zellner, Monica Trovo de Araújo and graduate student Jéssica Pereira Trentino for their important participation as members of the Judges Panel in this study. Finally, the authors extend a special thanks to Dr. RRebecca Rubin, author of the Interpersonal Communication Competence Scale, for her never-ending availability, openness and constructive suggestions in this work. Collaborations Puggina AC contributed to the conception and design, execution of the research, analysis and interpretation of the data, drafting of the article and the critical review of the relevant intellectual content. Silva MJP contributed to the critical review of the relevant intellectual content and the final approval of the version to be published. References 1. Rubin RB, Martin MM. Development of a measure of interpersonal communication competence. Commun Res Rep. 1994;11(1):33-44. 2. Beaton D, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000;25(24):3186-91. 3. Braga EM, Silva MJ. Comunicação competente: visão de enfermeiros especialistas em comunicação. Acta Paul Enferm. 2007; 20(4):410-4. 4. Mantha SS. Handbook on communication skills. Andhra Pradesh (India): Center for Good Governance, 2006. [cited em 01 jun 2010]. Available from: http://www.cgg.gov.in/publicationdownloads2a/softskills.pdf 5. Puggina AC, Silva MJ. Ética no cuidado e nas relações: premissas para um cuidar mais humano. Rev Min Enferm. 2009;13(4):599-605. 6. Araújo MM, Silva MJ, Puggina AC. A comunicação não-verbal enquanto fator iatrogênico. Rev Esc Enferm USP. 2007;41(3):419-25. 7. Goleman D, Boyatzis R. Social Intelligence and the biology of leadership. Harv Bus Rev. 2008;86(9):74-81. 8. Casarin FS, Pagliarin KC, Koehler C, Oliveira CR, Fonseca RP. Instrumentos de avaliação breve da comunicação: ferramentas existentes e sua aplicabilidade clínica. Rev CEFAC. 2011;13(5):917-925. 9. Melo RC, Silva MJ, Parreira PM, Ferreira MM. Competências relacionais de ajuda nos enfermeiros: validação de um instrumento de medida. Rev Esc Enferm USP. 2011;45(6):1387-95. 10. Fonseca RP, Parente MA, Côté H, Ska B, Joanette Y. Apresentando um instrumento de avaliação da comunicação à Fonoaudiologia Brasileira: Bateria MAC. Pró-Fono. 2008;20(4):285-92. 11.Reichenheim ME, Moraes CL. Operacionalização de adaptação transcultural de instrumentos de aferição usados em epidemiologia. Rev Saúde Pública. 2007;41(4): 665-73. 12. Filho Figueiredo DB, Silva Júnior JA. Visão além do alcance: uma introdução à análise fatorial. Opinião Pública. 2010; 16(1):160-85. 13.Damásio BF. Uso da análise fatorial exploratória em psicologia. Aval Psicol. 2012;11(2): 213-28. Acta Paul Enferm. 2014; 27(2):108-14. 113 Interpersonal Communication Competence Scale: Brazilian translation, validation and cultural adaptation Appendix - Validated and adapted version of the ICCS scale to Brazilian Portuguese Escala de Competência EM Comunicação InterpessoaL (ECCI) INSTRUÇÕES: aqui estão algumas afirmações sobre como as pessoas interagem entre si. Para cada afirmação, circule a resposta que melhor reflete SUA comunicação com os outros. Seja honesto em suas respostas e reflita, com muito cuidado, sobre o seu comportamento de comunicação. Marque só uma alternativa em cada item. Não deixe nenhuma questão em branco. Especifique a interação que será analisada: ( ) entre colegas de classe; ( ) entre colegas de trabalho; ( ) entre os membros da família; ( ) entre professor e aluno; ( ) entre profissional e paciente; ( ) outra (qual?): _____________ Se você quase sempre interage desta maneira, circule 5. Se você geralmente se comunica desta maneira, circule 4. Se você às vezes se comporta desta maneira, circule 3. Se você interage assim raramente, circule 2. Se você quase nunca se comporta desta maneira, circule 1. 114 1 Defendo meus direitos. 5 4 3 2 1 2 Em conversas com amigos, percebo não apenas o que eles dizem, mas o que não dizem. 5 4 3 2 1 3 Consigo persuadir os outros quanto à minha opinião. 5 4 3 2 1 4 Revelo como me sinto para os outros. 5 4 3 2 1 5 Assumo o controle das conversas em que estou envolvido, negociando os tópicos sobre os quais falaremos. 5 4 3 2 1 6 Digo às pessoas quando me sinto próxima delas. 5 4 3 2 1 7 Atinjo meus objetivos de comunicação. 5 4 3 2 1 8 Tenho dificuldade em me defender. 5 4 3 2 1 9 Deixo que os outros saibam que compreendo o que eles dizem. 5 4 3 2 1 10 Meus amigos realmente acreditam que me preocupo com eles. 5 4 3 2 1 11 Permito que os amigos vejam quem realmente sou. 5 4 3 2 1 12 Outros me descreveriam como caloroso, ou seja, afetuoso. 5 4 3 2 1 13 Expresso-me bem verbalmente. 5 4 3 2 1 14 Tento olhar os outros nos olhos quando falo com eles. 5 4 3 2 1 15 Quando sou injustiçado, confronto a pessoa que me injustiçou. 5 4 3 2 1 16 Outras pessoas acham que eu as entendo. 5 4 3 2 1 17 É difícil encontrar as palavras certas para me expressar. 5 4 3 2 1 Acta Paul Enferm. 2014; 27(2):108-14. Original Article Characterization of the intrahospital transport of critically ill patients Caracterização do transporte de pacientes críticos na modalidade intra-hospitalar Silmara Meneguin1 Patrícia Helena Corrêa Alegre2 Claudia Helena Bronzatto Luppi1 Keywords Transportation of patients; Patient transfer; Critical care; Inpatient; Patient care team Descritores Transporte de pacientes; Transferência de pacientes; Cuidados críticos; Pacientes internados; Equipe de assistência ao paciente Submitted January 14, 2014 Accepted March 20, 2014 Corresponding author Silmara Meneguin Distrito de Rubião Junior, unnumbered, Botucatu, SP, Brazil. Zip Code: 18618-970 [email protected] DOI http://dx.doi.org/10.1590/19820194201400021 Abstract Objective: Characterizing the transport of critically ill patients in an adult intensive care unit. Methods: Cross-sectional study in which 459 intra -hospital transports of critically ill patients were included. Data were collected from clinical records of patients and from a form with the description of the materials and equipment necessary for the procedure, description of adverse events and of the transport team. Results: A total of 459 transports of 262 critically ill patients were carried out, with an average of 51 transports per month. Patients were on ventilatory support (41.3 %) and 34.5 % in use of vasoactive drugs. Adverse events occurred in 9.4% of transports and 77.3 % of the teams were composed of physicians, nurses and nurse technicians. Conclusion: The transport of critically ill patients occurred in the morning period for performing computerized tomographies (CT scans) with patients dependent on mechanical ventilation and vasoactive drugs. During the transports the equipment was functioning, and the adverse events were attributed to clinical changes of patients. Resumo Objetivo: Caracterizar o transporte de pacientes críticos em unidade de terapia intensiva adulto. Métodos: Estudo transversal onde foram incluídos 459 transportes de pacientes críticos na modalidade intrahospitalar. Os dados foram coletados nos prontuários clínicos dos pacientes e em um formulário com a descrição dos materiais e equipamentos necessários ao procedimento, descrição de ocorrências adversas e da equipe que realizou. Resultados: Foram realizados 459 transportes de 262 pacientes críticos com média de 51 transportes por mês. Eram pacientes em suporte ventilatório (41,3%) e 34,5% em uso de drogas vasoativas. Em 9,4% dos transportes ocorreram eventos adversos sendo 77,3% das equipes compostas por médico, enfermeiro e técnico de enfermagem. Conclusão: Os transportes de pacientes críticos ocorreram no período da manhã, para realização de tomografia computadorizada, com pacientes dependentes de suporte ventilatório e drogas vasoativas. Os equipamentos durante o transporte estavam funcionando e, os eventos adversos ocorridos foram atribuídos a alterações clínicas dos pacientes. Faculdade de Medicina de Botucatu, Universidade Estadual Paulista “Júlio de Mesquita Filho”, Botucatu, SP, Brazil. Hospital Sírio Libanês, São Paulo, SP, Brazil. Conflicts of interest: no conflicts of interest to declare. 1 2 Acta Paul Enferm. 2014; 27(2):115-9. 115 Characterization of the intrahospital transport of critically ill patients 116 Introduction Methods The intrahospital transport of critically ill patients is associated with doing diagnostic or therapeutic exams in critically ill patients and requires replacement of support and monitoring equipment, in addition to continuing the drug infusion and transfer to a hospital stretcher.(1,2) The intrahospital transport is a period of instability and risk to patients, with the possibility of complications related to technical failures, physiological changes of patients, duration of transport, and with the team that performs it.(3-5) Furthermore, it must be taken into account that the sectors for which the patient is referred to not always have the same equipment that the intensive care unit. In this context, the indication, planning, implementation and stabilization after the procedure are of extreme importance in order to minimize complications and unnecessary risks to the patient.(3) The indication is medical and should be done by assessing the condition of patients and the risks and benefits of the procedure to which they will be submitted.(6) Transportation must ensure continuity of critical care and, therefore, must be efficient and safe in order to prevent the deterioration of patient’s condition.(3) Doing some diagnostic tests that involve the need for transporting critical patients alters the therapy in 24-39% of cases, hence it is necessary to weigh the risks and benefits.(7) The planning should be guided by the following triad: stabilization - especially of the respiratory and cardiovascular systems -, appropriate equipment and transport team.(3,6) At this stage, the intersectoral communication is essential because the place of destination of patients must be ready to receive them.(3) Execution refers to the transport itself, and the main goal of this phase is to maintain hemodynamic stability and avoid iatrogenic complications that may worsen the clinical picture. The analysis of aspects related to the intrahospital transport can contribute to enhance patient safety in order to minimize the risks. The aim of this study was to characterize the transport of critically ill patients in the intensive care unit of a tertiary public hospital. This is a cross-sectional study in an intensive care unit for adults with 25 beds in a tertiary public hospital in the interior of the state of São Paulo, southeastern region of Brazil. A total of 459 intrahospital transports of critically ill patients were done in the period between March and December, 2011. The study variables were the following: sociodemographic, medical diagnostics, patient transport characteristics, adverse events during transport, type of procedures and constitution of the transport team. Data were collected on the clinical records of patients and on a form available on the service. This form has a description of the materials and equipment necessary for the procedure, and the possible complications after its execution. The data were analyzed by the SPSS 15.0 for Windows, classified and presented as absolute and relative frequencies. The development of the study followed national and international standards of ethics in research involving human beings. Acta Paul Enferm. 2014; 27(2):115-9. Results During the study period 459 transports of 262 critically ill patients were done, with an average of 51 transports per month. Patients in critical condition were male (56.1%) with mean age of 57 years. The majority had medical and surgical disorders of various specialties, and mean hospital stay of 15.3 days in the adult intensive care unit. In the morning period, 229 transports (49.9%) were carried out, among which 202 (44.0%) to undergo computerized tomography (CT) scan, 27 (5.9%) for a magnetic resonance imaging (MRI) and 140 (30.5%) for other exams, namely: ultrasound, radiographic, hemodynamic, endoscopic and electroencephalograms. In addition to these, 90 (19.6%) transports were done to the surgery center (Table 1). The mechanical ventilator was used in 63.6% of cases, among which 76.3% were intubations and 23.7% were tracheostomies. Meneguin S, Alegre PH, Luppi CH Table 1. Intrahospital transport of critically ill patients Characteristics n(%) Período Morning 229(49.9) Afternoon 217(47.3) Evening 13(2.8) Type of transport Diagnosis 369(80.4) Surgery 90(19.6) Destination T CT Scan MRI 202(44.0) 27(5.9) Other diagnostic exams 140(30.5) Surgical center 90(19.6) In the transports carried out, 159 patients (34.6%) were on vasoactive drugs; norepinephrine was used in 132 cases (28.7%), sodium nitroprusside in 12 (2.6%), trinitrate propanetriol in 10 (2.2%) and dobutamine in 5 cases (1.1%). Regarding the transport team, 77.3% were composed of physicians, nurses and nurse technicians, 18.3% of nurses and nurse technicians, 2.9% of nurse technicians, and 1.5% of nurses. In most transports (94.3%) a carrying case containing materials and drugs for emergencies was among the included materials; 95.2% of transports had a manual resuscitator and 88.4% had a multiparameter monitor. The reported adverse events were attributed to patients (9.4%), institutional bureaucratic problems (1.1%) and technical failures with transport equipment (0.8%) (Table 2). Table 2. Adverse events during the transport of critically ill patients Adverse events n(%) Related to patients Hemodynamic 18(4.0) Respiratory 12(2.6) Neurological 10(2.2) Gastrointestinal 3(0.6) Related to the institution Cancellation of the exam 5(1.1) Related to equipment Battery failure (‘dead’) 4(0.8) Discussion The limits of the results of this study are related to the cross-sectional method that does not allow es- tablishing relations of cause and effect. On the other hand, the study results aim at contributing to the quality of the transport of critically ill patients in the institution. Each hospital should assess the need to have a specialized team to carry out the transportation of patients because the evidence that the occurrence of adverse events decreases when this feature is used is scarce in literature.(8) The use of rating systems for patients according to severity of cases may have applicability in clinical practice, but the prediction of transport related risks is not well determined, because some are inherent in the transportation itself and independent of distance and time. During the intrahospital transport of critically ill patients, the risks must be taken into account because patients may progress to cardiac arrest and death,(9) however some authors consider the transport safe and attribute the death to the severity of patients, regardless of carrying out the procedure or not.(10) Patients in critical conditions benefit from the resources in the intensive care unit to ensure their hemodynamic stability and have the assistance of a trained and specialized staff. However, during intrahospital transport, the same security is not always preserved. In this study, the recording of incidents was low (11.3% of cases) when compared to other studies, even considering the previous planning, which entails checking the condition of the equipment and materials needed for the transport. The results showed that adverse events related to patients were the most prevalent (9.4%) and are supported by a study carried out at two tertiary hospitals, where among 58 transports, 67% had cardiorespiratory changes.(11) Another analysis showed 26% of physiologic changes in 452 analyzed transports.(12) The prevalence of adverse events found in this study was consistent with the literature, in which the incidence of physiological complications ranged between 6 and 68%, given the diversity of the analyzed population, as well as the criteria used to define these changes.(13) According to data, the service has efficient personal and material resources to minimize complications in transporting patients. However, it is possible that the records are underreportActa Paul Enferm. 2014; 27(2):115-9. 117 Characterization of the intrahospital transport of critically ill patients ed, considering the severity of patients and the high number of transports carried out monthly (average of 51). The portable equipment to meet the needs of monitoring, continuous infusion of medications, and ventilatory support during the transport of critically ill patients must be in perfect working order and the battery charged. In this study, in four events (0.8%), the reported technical problems of the equipment were due to battery failure during the procedure, which suggests lack of planning. Regarding the physical structure, it is important to emphasize that the intensive care unit is located on the same floor that imaging diagnostics and other services. Moreover, these devices must be kept in the unit of origin and during the exam, connected to a power source. In an Australian hospital, a total of 191 complications occurred throughout a six-year period during the intrahospital transport of patients, among which 75 (39%) were related to equipment failures. The staff accompanying the transport of patients may come from another hospital or be group of professionals who work in the intensive care unit; regardless of this fact, they must be skilled and trained to carry out the procedure efficiently and effectively.(14,15) The organization of the transport of critically ill patients should be optimized from planning to execution. It is essential to define the components of the team and the number of professionals needed according to the clinical condition of the patient, but there must be at least two members, one being the nurse of the intensive care unit.(2) The presence of the physician is required for the transport of hemodynamically unstable patients, mechanically ventilated, with invasive monitoring and in use of vasoactive drugs.(2) In this study, 77.3% of the transports were carried out with the participation of a physician, a nurse and a nurse technician. In the remaining transports, 84 were done with the presence of a nurse and a nurse technician, 13 only with the nurse technician and seven with the nurse only. The rationale for reducing the workforce can be 118 Acta Paul Enferm. 2014; 27(2):115-9. attributed to the stability of the patient, but it does not meet the safety recommendations. There must be effective communication between teams to avoid unnecessary displacement of patients and, consequently, exposure to risks. In 1.1% of the patient transports carried out, the exam had been canceled and the patient had already been transported. The communication problems between the origin and destination units have been identified as one of the major factors contributing to the occurrence of adverse events during intrahospital transport, as shown on a study on this theme.(12) Therefore, communication is key during the planning of transport because it helps to reduce the waiting period for the exam, as well as the total time spent in the procedure. As for the place of destination, 44% of patients were transported for a tomography exam, which is consistent with results from other studies.(11,12) For some authors, only the abdominal CT scan and angiography result in changes of therapeutic conduct, in case of patients victim of trauma.(6) It was found that the equipment recommendations were followed during the transport. Adherence to the recommendations of required equipment for intrahospital transport was also evaluated in a study that identified the monitoring of oxygen saturation and blood pressure in 97% of cases, of heart rate in 90.5% of them, of cardiac monitoring in 84.5%, and of capnography in 75% of cases. (16) In situations where there is no multiparameter monitor available for transportation, it is recommended at the least the use of the pulse oximeter. The intrahospital transport of critically ill patients is a complex procedure that requires proper consideration of risks and benefits, plus the previous planning to minimize the risks. It is essential that it is systematized, carried out by a qualified team and with adequate material resources. Conclusion The transport of critically ill patients occurred in the morning period to undergo CT scan, and pa- Meneguin S, Alegre PH, Luppi CH tients depended on ventilatory support and vasoactive drugs. All the equipment used during transport was in working order and the adverse events were attributed to clinical changes in patients. Collaborations Meneguin S contributed to the project design, analysis and interpretation of data, drafting the article, critical revision of the intellectual content and approval of the final version to be published. Alegre PHC collaborated with the project design, data collection and data analysis. Luppi CHB participated in drafting the article and critical review of the relevant intellectual content. References 1. Almeida AC, Neves AL, Souza CL, Garcia JH, Lopes JL, Barros AL. [Intra-hospital transport of critically ill adult patients: complications related to staff, equipment and physiological factors]. Acta Paul Enferm. 2012;25(3):471-6. Portuguese. 5. Shirley PJ, Biion JF. Intra-hospital transport of critically ill patients: minimizing risk. Intensive Care Med. 2004;30(8):1508-10. 6. Caruana M, Culp K. Intrahospital transport of the critically ill adult: a research review and implications. Dimens Crit Care Nurs. 1998;17(3):146-56. 7. Nogueira VO, Marin HF, Cunha IC. [Online information about intrahospital transport of adults patients critical]. Acta Paul Enferm. 2005;18(4):390-6. Portuguese. 8. Mc Lenon M. Use of a specialized transport team for intrahospital transport of critically ill patients. Dimens Crit Care Nurs. 2004;23(5):225-9. 9. Damm C, Vandelet P, Petit J, Richard JC, Veber B, Bonmarchand G, et al. Complications during the intrahospital transport in critically ill patients. Ann Fr Anesth Reanim. 2005;24(1):24-30. 10. Szem JW, Hydo LJ, Fischer E, Kapur S, Klemperer J, Barie PS. High-risk intra-hospital transport of critically ill patients: safety and outcome of the necessary “road trip”. Crit Care Med. 1995;23(10):1660-6. 11.Zuchelo LTS, Chiavone PA. [Intrahospital transport of patients on invasive ventilation: cardiorespiratory repercussions and adverse events]. J Bras Pneumol. 2009;35(4):367-74. Portuguese. 12. Lahner D, Nikolic A, Marhofer P, Koinig H, Germann P, Weinstabl C, et al. Incidence of complications in intrahospital transport of critically ill patients – experience in an Austrian university hospital. Wien Klin Wochenschr. 2007;119(13-14):412-6. 13. Beckmann U, Gillies DM, Berenholtz SM, Wu AW, Pronovost P. Incidents relating to the intra-hospital transfer of critically ill patients. Intensive Care Med. 2004; 30(8):1579-85. 2. Warren J, Fromm RE, Orr RA, Rotello LC, Horst M, American College of Critical Care Medicine. Guidelines fot the inter and intrahospital transport of critically ill patients. Crit Care Med. 2004;32(1):25662. 14. Mazza BF, Amaral JL, Rosseti H, Carvalho RB, Senna AP, Guimarâes HP, et al. [Safety in intrahospital transportation: evaluation of respiratory and hemodynamic parameters. A prospective cohort study]. Sao Paulo Med J. 2008;126(6):319-22. Portuguese. 3. Japiassú AM. [Intra-hospital transport of critically ill patients]. Rev Bras Ter Intensiva. 2005;17(3):217-20. Portuguese. 15. Bérubé M, Bernard F, Marion H, Parent J, Thibault M, Williamson DR, et al. Impact of a preventive programme on the occurrence of incidents during the transport of critically ill patients. Intensive Crit Care Nurs. 2013;29(1):9-19. 4. Vieira AL, Guinsburg R, Santos AM, Peres CA, Lora MI, Miyoshi MH. [Intra-hospital transport of neonatal intensive care patients: risk factors for complications]. Rev Paul Pediatr. 2007;25(3):240-6. Portuguese. 16. Winter MW. Intrahospital transfer of critically ill patients; a prospective audit within Flinders Medical Centre. Anaesth Intensive Care. 2010;38(3):545-9. Acta Paul Enferm. 2014; 27(2):115-9. 119 Original Article Association between sleep disorders and frailty status among elderly Associação entre transtornos do sono e níveis de fragilidade entre idosos Ariene Angelini dos Santos1 Maria Filomena Ceolim1 Sofia Cristina Iost Pavarini2 Anita Liberalesso Neri1 Mariana Kátia Rampazo1 Keywords Geriatric nursing; Nursing care; Frail elderly; Geriatric assessment; Sleep disorders Descritores Enfermagem geriátrica; Idoso fragilizado; Avaliação geriátrica; Transtornos do Sono Submitted January 13, 2014 Accepted April 29, 2014 Corresponding author Ariene Angelini dos Santos Tessália Vieira de Camargo street, 126, Campinas, SP, Brazil. Zip Code: 13084-971 [email protected] DOI http://dx.doi.org/10.1590/19820194201400022 120 Acta Paul Enferm. 2014; 27(2):120-5. Abstract Objective: To analyze the association between nap frequency with frailty status, gender, age, education, family income and the five criteria of frailty. Methods: This is a cross-sectional study assessing 3,075 elderly who met the inclusion criteria. The sociodemographic characterization, cognitive status measures, frailty and nap status were performed. Data were analyzed using descriptive statistics and non-parametric tests for statistical inference. Results: Most elderly napped during the day (61.7%), with an average frequency of 5.9 days per week (SD=1.9). A significant association was found between nap frequency and the frailty dimension of “energy expenditure in physical activity”. Conclusion: No significant association was found between nap frequency and selected sociodemographic variables and frailty status among the elderly, except for the criterion of frailty “energy expenditure in physical activity”. Resumo Objetivo: Analisar a associação entre a frequência de cochilo com os níveis de fragilidade, gênero, idade, escolaridade, renda familiar e os cinco critérios de fragilidade. Métodos: Trata-se de um estudo transversal com avaliação de 3.075 idosos que atenderam aos critérios de inclusão. Foi realizada a caracterização sociodemográfica, as medidas de status cognitivo, de fragilidade e de cochilo. Os dados foram analisados por estatística descritiva, bem como testes não paramétricos para a estatística inferencial. Resultados: A maioria dos idosos cochilava durante o dia (61,7%), com uma frequência média de 5,9 dias por semana (DP=1,9). Associação significativa foi verificada entre a frequência de cochilo e o critério de fragilidade “gasto calórico em atividade física”. Conclusão: Nenhuma associação significativa foi verificada entre a frequência de cochilo e as variáveis sociodemográficas selecionadas e os níveis de fragilidade entre idosos, com exceção para o critério de fragilidade “gasto calórico em atividade física”. Universidade Estadual de Campinas, Campinas, SP, Brazil. Universidade Federal de São Carlos, São Carlos, SP, Brazil. Conflict of interest: there are no conflicts of interest to be declared. 1 2 Santos AA, Ceolim MF, Pavarini SC, Neri AL, Rampazo MK Introduction Nap among elderly is common, i.e. it is a habit of daily routine.(1,2) In places of warm climates, such as China, Latin America and the Mediterranean, napping is a habit considered a healthy lifestyle for the elderly.(3) The increased trend to sleep in the afternoon makes naps to be more likely to happen at this time of the day. A nap can be planned or unplanned. Intentional naps can be caused by any drowsiness or by changes in lifestyle that allow sleep during the day, such as, for example, the post-retirement period. Unintentional naps during the day are more related to pathological conditions.(4) Recent findings indicate that the presence of comorbidities is highly associated with the likelihood of regular naps reports by the elderly.(5) Comorbidities are also common among frail elderly.(6) Sleep disorders and the frailty syndrome are increasingly common in aging.(7) Sleep disorders are characterized by biological processes similar to those observed in the frailty.(8) Problems related to sleep can exacerbate the course of a comorbidity or psychiatric disease, thereby, increasing vulnerability to the development of frailty.(9) The association between sleep disorders and frailty can be seen as bidirectional, in which fragility can lead to disorders in the pace of activity/rest with irregular cycles, which are commonly observed in the elderly with chronic diseases.(10) Several studies have found that daytime sleepiness and napping are associated with increased risk of mortality, with cardiovascular diseases, falls, cognitive impairment and decreased quality of nocturnal sleep in elderly.(11-16) However, the literature are scarce in relation to studies on nap and frailty. Given the above, the present study aimed to analyze the association between nap frequency with frailty status, gender, age, education, family income and the five criteria of frailty. Methods This is a cross-sectional study with 3,075 elderly residents in seven cities of geographical regions of Brazil, except for the Midwest region. The elderly were recruited at their home, in urban census sectors, randomly assigned. Research personnel were trained and followed a script composed of personal presentation, research presentation and invitation to participate, according to an instruction manual built and pre-tested for the study. Inclusion criteria were: age to be greater or equal to 65 years old, understand instructions, be a permanent resident in the household and in the census sector. Exclusion criteria were: a) elderly patients with severe cognitive impairment suggestive of dementia, evidenced by problems with their memory, attention, spatial and temporal orientation, and communication or observed by personnel; b) elderly who were using a wheelchair or who found themselves temporarily or permanently bedridden; c) severe sequelae of stroke, with localized loss of strength and/or aphasia; d) patients with Parkinson’s disease in severe or unstable stage, with severe impairment of motor skills, speech or affection; e) people with severe deficits in hearing or vision, which strongly hamper communication; and f ) elderly who were terminally ill. The groups underwent sociodemographic characterization and measures of cognitive, frailty and nap status. At the beginning of data collection, the elderly were assessed for cognition through a screening test called the Mini Mental State Examination (MMSE).(17) Elderly who scored above the cutoff score, according to their education, participated in all interviews and assessments. The others were discharged and received orientations on health care and a health booklet. Sociodemographic characteristics variables used were: gender, age, marital status, skin color/race, education, family income in minimum wages, family living arrangements, current work and retirement. For the frailty assessment, the definition adopted followed the one proposed by a North American researchers group.(18)There are five elements of the operational definition of the syndrome or frailty phenotype: 1) Unintentional Acta Paul Enferm. 2014; 27(2):120-5. 121 Association between sleep disorders and frailty status among elderly weight loss greater than or equal to 4.5 kg or 5% of body weight in the previous year; 2) self-report exhaustion considered the manifestation of fatigue in a statement that three or more days of the week the elderly felt that he/she needed to make a lot of effort to manage the duties or has failed to carry out his/her normal duties; 3) low grip strength measured with a portable hydraulic dynamometer in the dominant hand, adjusted for gender and body mass index (BMI). Three measures of grip strength were performed, the arithmetic means were used; 4) low level of energy expenditure measured in kilocalories and adjusted for gender, assessed from self-reported physical activity and domestic work performed in the last seven days; 5) low gait speed indicated by the average time taken to travel the distance of 4.6 m, with adjustments for height and gender. Three measures of gait speed were performed and used the arithmetic mean. The presence of three or more of the five characteristics of the phenotype meant frail, one or two meant intermediate frail and none of the characteristics indicated a not frail elderly. Naps were assessed by self-reporting answers using a specific question in the Minnesota Leisure Time Activities Questionnaire.(19) It was asked to the elderly if he/she slept or napped during the day (yes or no). If so, they were also asked about how many days a week they napped. Data analysis was performed with SAS (Statistical Analysis System) version 9.2 for Windows. Descriptive statistics were used, as well as non-parametric tests for statistical inference, due to non-normal distribution of the variables, confirmed by the Kolmogorov-Smirnov test. To compare the variables: frail status, frail criteria, gender, age, education, family income with respect to the variable nap frequency, the nonparametric Mann-Whitney and Kruskal-Wallis tests were applied. The Mann-Whitney test was used for comparisons between two groups (categories) and the Kruskal-Wallis test between three or more groups (categories). In cases where the null hypothesis of the Kruskal-Wallis test was rejected, the post-test 122 Acta Paul Enferm. 2014; 27(2):120-5. was applied. We defined the level of statistical significance of 5% (p≤0.05). The study followed the development of national and international standards of ethics in research involving human beings. Results The participants were mostly female (67.4%) and from the age group 65-69 years (35.3%). Most elderly were married or lived with a partner (48.1%), followed by widowed (36.1%); white (53.7%), with one to four years of education (50.1%), with a monthly family income from 1.1 to 3.0 minimum wages (48.8%), living alone with their children (27.4%). Most of these elderly did not work at that time (85.0%), were retired (76.2%) and were intermediate frail (51.9%). Most napped during the day (61.7%) with an average frequency of 5.9 days per week (SD=1.9), minimum of a day and maximum of seven days a week. Table 1 present the results of the comparison between the variables of interest and the weekly nap frequency. There was a significant association between the nap frequency and education of the elderly residents of the community (p=0.0323). However, no difference was found after applying the post-test of Kruskal-Wallis. In this case, we chose to consider that there is no statistically significant difference between education and the weekly nap frequency. Table 2 shows the results from the comparison of the five criteria of frail and weekly frequency of naps. There was a significant association between the criterion “energy expenditure in physical activity” and the weekly nap frequency of the elderly community. The elderly considered frail in this criterion, i.e., those with low rates of energy expenditure in physical activity showed an average of 6.1 naps during the week, slightly higher than not frail elderly to this aspect. Santos AA, Ceolim MF, Pavarini SC, Neri AL, Rampazo MK Table 1. Study variables and nap frequency on weekdays Variable Nap frequency on week days n* Mean SD Minimum Q1 Median Q3 Maximum 692 5.9 1.9 1.0 5.0 7.0 7.0 7.0 Frail Not frail 0.4274† Intermediate frail 920 5.9 1.9 1.0 5.0 7.0 7.0 7.0 Frail 173 6.0 1.9 1.0 7.0 7.0 7.0 7.0 0.4705‡ Gender 658 6.0 1.8 1.0 5.0 7.0 7.0 7.0 1.155 5.9 1.9 1.0 5.0 7.0 7.0 7.0 65 to 69 618 5.8 1.9 1.0 5.0 7.0 7.0 7.0 70 to 74 538 5.9 1.9 1.0 5.0 7.0 7.0 7.0 Male Female 0.1321† Age group (years) 75 to 79 80 + 376 5.8 2.0 1.0 5.0 7.0 7.0 7.0 281 6.1 1.7 1.0 7.0 7.0 7.0 7.0 346 6.0 1.8 1.0 5.0 7.0 7.0 7.0 0.0323† Education (in years) 0 1 to 4 904 5.8 2.0 1.0 5.0 7.0 7.0 7.0 5 to 8 329 5.9 1.9 1.0 5.0 7.0 7.0 7.0 9+ 232 6.2 1.7 1.0 7.0 7.0 7.0 7.0 169 6.0 1.8 1.0 6.0 7.0 7.0 7.0 0.8837† Family income (MW) 0 to 1,0 p-value 1,1 to 3,0 727 5.8 1.9 1.0 5.0 7.0 7.0 7.0 3,1 to 5,0 346 5.9 1.9 1.0 5.0 7.0 7.0 7.0 5,1 to 10,0 180 5.9 1.9 1.0 5.0 7.0 7.0 7.0 >10,0 102 5.9 1.8 1.0 5.0 7.0 7.0 7.0 * The different sample numbers for each variable refers to the lack of answers in the study protocol; SD – standard deviation; † p-value obtained through Kruskal-Wallis test; ‡ p-value obtained through Mann-Whitney test; MW – Minimum wage Table 2. Five criteria for frailty and nap frequency Variable Nap frequency on week days n Mean SD Minimum Q1 Median Q3 Maximum Weight loss Not frail Frail 0.4754 1.394 5.9 1.9 1.0 5.0 7.0 7.0 7.0 312 6.0 1.8 1.0 5.50 7.0 7.0 7.0 Exhaustion Not frail Frail 0.1241 1.349 5.9 1.9 1.0 5.0 7.0 7.0 7.0 407 5.8 2.0 1.0 4.0 7.0 7.0 7.0 Grip strength Not frail Frail 0.4077 1.400 5.9 1.9 1.0 5.0 7.0 7.0 7.0 370 5.9 1.9 1.0 5.0 7.0 7.0 7.0 Physical activity Not frail Frail 0.0324 1.448 5.8 1.9 1.0 5.0 7.0 7.0 7.0 351 6.1 1.8 1.0 7.0 7.0 7.0 7.0 Gait speed Not frail Frail p-value* 0.3519 1.400 5.9 1.9 1.0 5.0 7.0 7.0 7.0 375 5.9 1.9 1.0 6.0 7.0 7.0 7.0 SD – standard deviation; * p-value obtained by Mann-Whitney test Acta Paul Enferm. 2014; 27(2):120-5. 123 Association between sleep disorders and frailty status among elderly Discussion This study had some limitations, such as: the results may not apply to other groups of elderly inserted in different contexts; analysis were adjusted for various factors, but the possibility of residual confounding cannot be eliminated; we used only subjective measures of sleep, which would result in lower stability of the measures; the study design was cross-sectional and causality cannot be asserted between the variables; furthermore, the presence of comorbidities was not assessed in this study, which may influence the nap and/or frailty. Nurses must take into account the in-depth assessment with elderly who have joined health services, seeking to study sleep issues in order to achieve early detection of problems and the development of actions to minimize these complaints and, thus, avoid late action. Significant association was found between the criterion “energy expenditure in physical activity” and the weekly nap frequency for the elderly. The elderly that had low rates of energy expenditure in physical activity napped more frequently than not frail elderly. Studies conducted in the U.S.A have corroborated the findings of our study, which showed an existing significant association between daily nap and physical activity: women who napped daily were less likely to go walking, i.e. 10.8% of them.(11,14) Two other studies from the U.S.A addressed exhaustion and have also corroborated our findings. One revealed that the more a person present fatigue, the more frequent naps will be.(16) The other found that 37.5% of men and 28.9% of women were napping at least seven times a week and the short duration of sleep and early awakening were associated with symptoms of exhaustion.(20) The time devoted to physical activities decreases over the years, due to physiological changes of aging, the presence of comorbidities and functional disability. Some elderly choose activities that require less physical effort and frequent naps possibly by having some limitation in functional capacity.(21) 124 Acta Paul Enferm. 2014; 27(2):120-5. Physical inactivity or fatigue may indicate a symptom of depression or physical illness,(22) which can cause social isolation. Some studies have indicated the association between depressive symptoms and naps.(11,16) Thus, it can be inferred that if an elderly is having depressive symptoms, probably he/ she will not have desirability to perform physical activities and, thus, are more prone to nap. For some authors, physical inactivity favors naps.(23) Another aspect worth mentioning is medication use by the elderly. There are medications that can induce the elderly to sleep, such as antihistamines, antidepressants, benzodiazepines,(24) making the elderly to feel unwell for practicing physical activities as a result of excessive daytime sleepiness.(21) The prescription of medicines to the elderly must be accurate and monitored, as some drugs can impair gait and cognition of these subjects, and it may cause drowsiness and indisposition, leading them to physical inactivity.(24) Deleterious effects of frailty, such as loss of physical function and reduced socialization, can negatively affect social activities, physical exercise and exposure to sunlight outdoors. This could alter the circadian rhythm, leading to highly irregular hours for wakefulness and sleep. These disorders in the circadian rhythm are prevalent in chronic patients.(25) This study presented several positive aspects, including: unprecedented nature of the subject, significant sample size, national scope, the fact that the elderly are living in the community and they were not selected on the basis of sleep disorders or frail status, validated measures of frailty and identical to those used in the definition proposed by Linda Fried. To avoid the influence or even change the findings, the elderly with cognitive impairment were excluded at the baseline of this research. The results pointed to the need for inclusion of the elderly in groups of physical activities that can be developed in Basic Health Units, which aims at health promotion and disease prevention, thus improving the quality of life of these people and the use of time by part of them. Santos AA, Ceolim MF, Pavarini SC, Neri AL, Rampazo MK Conclusion No significant association was found between the nap frequency and the variables of interest for this study, with only one exception for the criterion of frailty “energy expenditure in physical activity”. Acknowledgements We acknowledge the financial support of the Coordination of Improvement of Higher Education Personnel (CAPES, PhD scholarship for Ariene Angelini Mariana dos Santos and Katia Rampazo) and to coordinator of the study FIBRA, Anita Liberalesso Neri, PhD by providing the data for dissemination of the study. Collaborations Santos AA contributed to the research design, conception, analysis and interpretation of data, drafting the article, critical revision of the manuscript and approved the final content. Neri AL collaborated with the research design. Ceolim MF and Pavarini SCI contributed to the research design, conception, analysis and interpretation of data, critical revision of the manuscript and approved the final content. Rampazo MK collaborated with the critical review of the manuscript and approved the final content. dwelling men. J Am Geriatr Soc. 2009;57(11):2085-93. 8. Fragoso CA, Gill TM. Sleep complaints in community-living older persons: a multifactiorial geriatric syndrome. J Am Geriatr Soc. 2007;55(11):1853-66. 9. Roth T, Roehrs T, Pies R. Insomnia: pathophysiology and implications for treatment. Sleep Med Rev. 2007;11(1):71-9. 10.Ensrud KE, Blackwell TL, Ancoli-Israel S, Redline S, Cawthon PM, Paudel ML, et al. Sleep disturbances and risk of frailty and mortality in older men. Sleep Med. 2012;13(10):1217-25. 11. Stone KL, Ewing SK, Ancoli-Israel S, Enrusd KE, Redline S, Bauer DC, et al. Self-reported sleep and nap habits and risk of mortality in large cohort of older women. J Am Geriatr Soc. 2009;57(4):604-11 12. Tanabe N, Iso H, Seki N, Suzuki H, Yatsuya H, Toyoshima H, Tamakoshi A. Daytime napping and mortality, with a special reference to cardiovascular disease: the JACC study. Int J Epidemiol. 2010;39(1):233–43. 13. Campbell SS, Murphy PJ, Stauble TN. Effects of a nap on nighttime sleep and waking function in older subjects. J Am Geriatr Soc. 2005;53(1):48-53. 14.Stone KL, Ewing SK, Lui LY, Ensrud KE, Ancoli-Israel S, Bauer DC et al. Self-reported sleep and nap habits and risk of falls and fractures in older women: the study of osteoporotic fractures. J Am Geriatr Soc. 2006; 54(8):1177–83. 15. Ficca G, Axelsson J, Mollicone DJ, Muto V, Vitiello MV. Naps, cognition and performance. Sleep Med Rev. 2010;14(4):249-58. 16.Owens JF, Buysee DJ, Hall M, Kamarck TW, Lee L, Strollo PJ, et al. Napping, nighttime sleep, and cardiovascular risk factors in mid-life adults. J Clin Sleep Med. 2010;6(4):330-5. 17. Folstein MF, Folstein SE, McHugh PR. “Mini-Mental State”. A practical method for grading the cognitive status of patients for the clicician. J Psychiatr Res. 1975;12(3):189-98. 18. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol Biol Sci Med Sci. 2001;56(3):M146-56. References 19. Taylor HL, Jacobs DR, Schucker B, Knudsen J, Leon AS, Debacker G. A questionnaire for the assessment of leisure time physical activities. J Chron Dis. 1978;31(12):741-55. 1. Xu Q, Song Y, Hollenbeck A, Blair A, Schatzkin A, Chen H. Day napping and short night sleeping are associated with higher risk of diabetes in older adults. Diabetes Care. 2010;33(1):78–83. 20.Goldman SE, Ancoli-Israel S, Boudreau R, et al. Sleep problems and associated daytime fatigue in community-dwelling older individuals. J Gerontol A Biol Sci Med Sci. 2008; 63:1069–75. 2. Milner CE, Cote KA. Benefits of napping in healthy adults: impact of nap length, time of day, age, and experience with napping. J Sleep Res. 2009;18(2):272–81. 21. Back FA, Fortes FS, Santos EH, Tambelli R, Menna-Barreto LS, Louzada FM. Sincronização não fótica: o efeito do exercício físico aeróbio. Rev Bras Med Esporte. 2007;13(2):138-42. 3. Lan TY, Lan TH, Wen CP, Lin YH, Chuang YL. Nighttime sleep, chinese afternoon nap, and mortality in the elderly. Sleep. 2007;30(9):1105-10. 22.Araújo LA, Bachion MM. Diagnósticos de enfermagem do padrão mover em idosos de uma comunidade atendida pelo Programa Saúde da Família. Rev Esc Enferm USP. 2005; 39(1):53-61. 4. Martin JL, Ancoli-Israel S. Napping in older adults. Sleep Med Clin. 2006;1(2):177-86. 5. Vitiello MV. Sleep in normal aging. Sleep Med Clin. 2006;1(2):171-6. 6. Ottenbacher KJ, Ostir GV, Peek MK, Al SS, Raji MA, Markides KS. Frailty in older Mexican Americans. J Am Geriatr Soc. 2005;53(9):1524-31. 7. Ensrud KE, Blackwell TL, Redline S, Ancoli-Israel S, Paudel ML, Cawthon PM, et al. Sleep disturbances and frailty status in older community- 23. Geib LT, Cataldo Neto A, Wainberg R, Nunes ML. Sono e envelhecimento. Rev Psiquiatr. 2003;25(3):453-65. 24. Araújo CL, Ceolim MF. [Sleep quality of elders living in long-term care institutions]. Rev Esc Enferm USP. 2010; 44(3):619-26. Portuguese. 25. Fragoso CA, Gahbauer EA, Ness PH, Gill TM. Sleep–wake disturbances and frailty in community-living older persons. J Am Geriatr Soc. 2009;57(11):2094–100. Acta Paul Enferm. 2014; 27(2):120-5. 125 Original Article Revelations expressed by preschool children with chronic diseases in outpatient treatment Revelações manifestas por crianças pré-escolares portadoras de doenças crônicas em tratamento ambulatorial Ana Paula Keller de Matos1 Priscilla Caires Canela1 Aline Oliveira Silveira2 Monika Wernet1 Keywords Ambulatory care; Pediatric nursing; Chronic disease; Play and playthings; Qualitative research; Child, preschool Descritores Assistência ambulatorial; Enfermagem pediátrica; Doença crônica; Jogos e brinquedos; Pesquisa qualitativa; Préescolar Submitted January 12, 2014 Accepted April 14, 2014 Abstract Objective: To identify and describe the revelations expressed by children with chronic diseases in outpatient treatment. Methods: This was a qualitative study guided by the theoretical framework of symbolic interactionism and Bardin’s thematic content analysis. Data was collected through therapeutic play sessions with four preschool children who live with chronic illness. Results: Four thematic categories that characterize the daily life of these children were identified: “Interactions,” “Fight,” “Support” and “Doubt.” Conclusion: The children in this study seek to transform their daily interactions with a view toward being recognized as individuals with voices, desires, wills and opinions. Resumo Objetivo: Identificar e caracterizar as revelações manifestas por crianças portadoras de doenças crônicas em tratamento ambulatorial. Método: Tratou-se de uma pesquisa qualitativa, norteada pelos referenciais do Interacionismo Simbólico e da análise de conteúdo temática de Bardin. A coleta dos dados foi desenvolvida por meio de sessões de brinquedo terapêutico com quatro crianças pré-escolares que convivem com a doença crônica. Resultados: Identificaram-se quatro categorias temáticas que marcam o cotidiano destas crianças: “Interações”, “Luta”, “Apoio” e “Dúvida”. Conclusão: Estas crianças buscam transformar as interações de seu cotidiano com vistas a serem reconhecidas enquanto pessoas com voz, desejos, vontades, detentoras e formadoras de opinião. Corresponding author Ana Paula Keller de Matos Washington Luís Highway, Km 235, São Carlos, SP, Brazil. Zip Code: 13565-905 [email protected] DOI http://dx.doi.org/10.1590/19820194201400023 126 Acta Paul Enferm. 2014; 27(2):126-32. Universidade Federal de São Carlos, São Paulo, SP, Brazil. Universidade de Brasília, Brasília, DF, Brazil. Conflict of interest: there are no conflicts of interest to declare. 1 2 Matos AP, Canela PC, Silveira AO, Wernet M Introduction Children living with chronic illness often must live with timetables and routines that are imposed on them, marked by contact with different health care professionals, numerous procedures (hospitalizations and treatments, among others) and deprivations (food, play and social contact, among others).(1-3) This impacts their social conviviality, causing feelings such as fear, anxiety and tension that are amplified among preschool children, whose capacity for preparation and understanding is limited, along with their ability to express feelings and needs.(1-3) Studies that explore the phenomenon of living with chronic illness in childhood are generally concentrated on the perspective of the family, with emphasis on the primary caregiver.(1) There are few studies that seek to understand the child’s perspective. This study adopted the guiding question “What marks the daily lives of preschool children who live with chronic illness?”, with the aim of characterizing the revelations expressed by children without cognitive impairment who are living with chronic diseases. Methods This was a field study using a qualitative approach, which adopted therapeutic play as the strategy for data collection. Therapeutic play is structured based on the cathartic function of play, and has been indicated as a resource to access the perspective and understand the needs of children, especially in the preschool phase.(4-6) This study and others have adopted this strategy for data collection.(7,8) Given the objectives of this study, the theoretical framework of symbolic interactionism was chosen because it affirms that children are actors in their experience, and the meanings from which actions occur are established in their interactions. In this framework, a human being’s interactions and actions are influenced by what is happening in the present, and at the same time aspects of an individual’s lived past are applied. In this sense, every phenomenon must be comprehended and understood from the perspective of the person who lives it.(9) The study was developed in an outpatient care unit of the Sistema Única de Saúde (SUS), Brazil’s public health care system, in a city in the interior of São Paulo state. The facility provides physical therapy, psychological counseling, occupational therapy and nursing care for chronically ill children and their families. The study subjects were child users of this service who met the inclusion criteria: carrier of a chronic disease; treated exclusively in outpatient care for more than two years; no cognitive impairment; and preschool age (three to five years and 11 months). Seven children were potential subjects, but only four participated in the study. The other three were excluded for the following reasons: one for not attending scheduled meetings three consecutive times, who was considered as not wanting to participate; another due to transportation difficulties; and a third because the child refused to participate. A total of 29 therapeutic play sessions were conducted with the four remaining children, totaling 1,115 minutes. Laurence Bardin’s system of thematic content analysis was adopted as the methodological approach. This is part of a set of techniques for analysis of communication processes with a view to understanding the content transmitted.(10) It identifies three steps: (1) pre-analysis, which includes initial reading of the material to give order to the data; (2) exploration of the material, with the aim of coding and classifying what is revealed by the articulation of concepts and processes of the phenomenon in focus; and (3) treatment and interpretation of the outcomes obtained, which involves the process of critical reflection on the results.(10) The development of study adhered to national and international standards for ethics in research involving humans. Results Analysis of the data revealed that the children seek recognition as individuals with voices, deActa Paul Enferm. 2014; 27(2):126-32. 127 Revelations expressed by preschool children with chronic diseases in outpatient treatment sires, wills and opinions. Their everyday experiences can be characterized by these thematic categories: “Interactions,” “Fighting,” “Support” and “Doubt.” The thematic category “Interactions” reveals that the children’s social relationships, especially with professionals and caregivers, are marked by unidirectionality, imposition and valuing of results. They are relationships based on power over the children, sustained by the belief that the adults know what’s best for them. Commands for action predominate, and obedience is always expected. In health care, professionals show little sensitivity and consideration, treating children according to protocol and in an impersonal manner, even when the children express suffering. The professionals in this study demonstrated that they were focused on implementation of interventions to achieve therapeutic results, while expecting the child to cooperate and obey. Given this relational context, the coping mechanisms adopted by the child are to conform and incorporate the rationale that it is “for your own good.” While playing medical consultation, the child begins to examine the grandmother doll. The child “draws” the blood, and then immediately throws the grandmother doll into the corner and says, “Next.” In another session, this same child, in the same story plot, starts by crying, “Next.” [...] The child asks, “What have you got?” and, without waiting for the response, says, “You have to come back here on Wednesday, you have an infection.” The researcher responds, “That’s okay,’ and that she will leave now. Superman replies “No,” pulls her arm to draw blood, and does the action of drawing blood, including “looking” for the vein, always with brusque movements, without eye contact, centered on the arm and the syringe. And he says dryly, “You have to drink plenty of water and come back on Wednesday. Go, you can go. It’s for your own good.” Superman – 3rd and 8th sessions. In daily interactions with their caregivers, it is reinforced that the health care professional is the absolute authority, always to be obeyed. The children suppress their affectivity and sensitivity in order to be able to carry out the professional’s recommendations. 128 Acta Paul Enferm. 2014; 27(2):126-32. When playing giving medication to the baby, the child reproduces the drug intervention with skill, precision and sudden movements, and says, “I’m going to put in the medicine. I’m putting in a lot of medicine, take it, because the doctor said to, it is for your own good. Take it all. He said to.” The child sits in a chair, and with precise and firm handling gives the bottle to the doll, saying to the doll, “Very good, you took everything. It’s for your own good.” Wonder Woman – 2nd session. The thematic category “Fighting” shows the child’s attempts to become stronger in the face of anxiety and discomfort. All of the children incorporated fighting as one of the plots of the therapeutic play sessions, when objects, people and animals engaged in disputes and aggression, and the strongest dominated the weakest. Throughout the sessions, and with the development of their experiences, the children reduced their aggressiveness and fighting time, and incorporated the idea that they could both be strong and win. Concordant with this placement, it is emphasized that the fighting preceded the catharsis. Picks up the lion and simulates biting the alligator. Does the reverse, alligator bites the lion. [...] Grabs the cow, dinosaur and lion, lies down in the middle, the toys around him. Plays with these three animals for ten minutes, then the lion bites the dinosaur, now the dinosaur bites the lion. Both bite the cow, which falls down. [...] After various fights, the child feels confident expressing aggression without seeking eye contact with the adult to identify her judgment of the aggressive actions. As the session progresses, attacks with no concern for the others around him. Stone Man - 3rd session. Fighting in therapeutic play seems to be a resource by which the children are empowered to manage their experiences in relationships. The children appear to seek to be the dominators. Throughout the sessions, through fighting, the children gain the courage to explore their history and suffering with authenticity. Play fighting encourages the children to express their discomfort with their position of being dominated, but also allows them to appropriate their strength.(...) Attacks the dinosaur, but says he is still alive. “There is still one life,” he explains. Soon after, he attacks and knocks down the dinosaur. He smiles and says, “I am Matos AP, Canela PC, Silveira AO, Wernet M the strongest on earth,” and then begins the section of play in which he expresses his suffering. Superman – 4th session. The thematic category “Support” represents the children’s need to be accepted, which they experience in “differentiated” relationships, i.e., those with people sensitive to their situations, suffering and desires. In these relationships, the children perceive others’ efforts to welcome them, offer love and affection, and demonstrate care for them. These people are most often family members who offer protection and advantages, and signal the child’s emotional fragility to others. These people are well-loved by the child, and to cease living with them, either by death or family separation, causes suffering and triggers the desire to reestablish contact. In this study, these people were the grandfather, mother and father. The session of one child who received emotional support from his grandfather is highlighted below. Plays with the wheelchair, pushing it from one side to the other, opening and closing it. Is thoughtful, says he had two grandfathers, one died and the other is now under [...] The one who died was called P., and used a wheelchair, says the child. [....] Places the doll of the child (girl) in the wheelchair, and the dolls representing the father and mother behind it. Says this is how it was. Plays a little longer, and leaves it, turning to the sword, hitting the dinosaur with it. Hits the dolls on the chair with the sword. Squeezes her doll tightly (security object that she brings to the session). Is quiet. Wonder Woman - 1st and 5th sessions. The thematic category “Doubt” relates to social behavior imposed on the child that restricts the child’s authentic behavior. This makes the child fearful, with doubts and difficulties regarding how to act. Plays with the researcher, putting the blue lizard on her as if it was walking, the lizard “goes” to the neck and “bites.” Soon after, the child hugs the researcher, and smiles at her. He tosses the lizard away, and grabs the sword. He pushes the animals into a corner, gives the little dinosaur to the researcher, and asks what he should do. He shows how to act: hitting the big dinosaur. Researcher does what he asks. He smiles and hits too. Stone Man - 3rd and 6th sessions. In the initial social interactions, the children were unsure of how they could and should act, a result of their insecurity about being accepted. When they perceived that a given behavior was acceptable, they tended to reproduce it, even if they wanted to act differently. When in doubt as to whether the desired behavior was acceptable, the children expressed discrete, spontaneous and authentic manifestations, and waited for the impact of the behavior in order to decide whether or not to continue. However, finding the opportunity and permission to be authentic brought them joy, and they continued to manifest their own way of being. Therapeutic play is a potential space for authentic behavior, which ends by expressing suffering. At the end of the sessions and/or termination of the study, the children stated that they would miss it. The researcher signals to the child that it is time to end the session. The child says he chose to play until he got tired, and the researcher again explains the rules. The child argues that he chose to play. (…) When the toys are put away, the child becomes quiet and thoughtful. He grabs the gun, handles it, faces the researcher, points the gun at her face and shoots. He also shoots to the side, and puts the gun next to the bag. Superman – 4th session. It was identified that these children expect commands about how they should or should not be. They discover in some of the interactions that they can be authentic, which encourages them to be who they really are, and express their wishes. They rarely experience such opportunities. Says that the doll was crying because she wanted her mom. “Makes” juice and is very involved with this act, looking from time to time at the researcher and observer. Looks at her stepmother, and gives food to the mother and father dolls. She-Ra - 1st session. Discussion This study was limited to a qualitative-interpretative approach to characterization of the manifestations of preschool children living with chronic illness. Therefore, Acta Paul Enferm. 2014; 27(2):126-32. 129 Revelations expressed by preschool children with chronic diseases in outpatient treatment expansion of the experience is needed, with different methodological approaches and new sample groups. The thematic categories revealed in the experiences of these preschool children with chronic illnesses provide a theoretical and practical basis to guide nurses’ interactions with these children, from the perspective of care centered on the children as individuals, with a view towards recognition and support of their expressions, needs and autonomy. In this sense, this study can contribute to strategies for the development of advanced practice and application of ethical principles in pediatric care, according to the guidelines of the International Council of Nurses. The children in this study revealed that their everyday experience is regimented, driven by relationships of command and imposition, and that they strongly seek to expand their opportunities to be authentic in their behavior. They seek understanding of their needs, valuation of their efforts and recognition of their capabilities. The children struggle for these in a scenario that tends to repress them. Autonomy is essential to the empowerment of children living with chronic illness, and requires close, understanding relationships that offer possibilities of choice.(11) The children in this study seek autonomy in a shy and covert manner, questioning their power and possibilities. Being heard is an acute need in the process of achieving autonomy,(8,11) and this need was identified in this study, particularly in the thematic category “Interactions.” Yet similar to another study,(12) the professionals silence the children’s voices and impose behavior. To transform this scenario requires listening to the child as part of care.(11,13) In this study and another, the professional-child relationship was focused on results centered on the disease and impersonality.(14) This study confirmed that an affectionate and differentiated bond(7,15) brings a sense of security,(13) promotes confidence in oneself and others, and consequently relieves pain and increases resiliency.(16) Children experiencing hardships and unpleasant symptoms resulting from a chronic condition need social support “to create strategies that facilitate coping with stress and exhaustion”. 130 Acta Paul Enferm. 2014; 27(2):126-32. In this sense, social interactions can encourage the construction of new meanings for the elements of their history, thereby empowering them.(17) In the absence or loss of this bond, pain and depression may be present.(16) These observations are in conjunction with those presented in the thematic category “Support.” It is emphasized that living with chronic illness in childhood is pervaded by the possibility of social isolation, due to insecurity about being accepted.( 11) Something similar was also revealed by the children in this study, who are faced with the fear of being inadequate, or not meeting the expectations placed on them. It is noteworthy that support is usually found within the family,(7,11) as occurred in this study. Loving relationships and demonstrations of interest in the child generate care and authenticity, and promote comfort and relational security.(13) In contrast, in interactions with professionals, barriers are structured into the hierarchy. Based on the above, it is clear that seeking to understand the children’s experiences, as well as being respectful of their decisions and limits, are guides for relationships with them, and are basic to human care, where dialogue, affection and co-construction are paramount and amplify the children’s satisfaction. (11,18) When the children can understand the place of the disease and its consequences in their lives, they tend to calibrate their own identity for coping. Thus, it is a priority to invest in the full protection of these children, the first step being to respect them as individuals, regardless of their developmental stage. Listening to them and allowing them to be co‑participants in their history needs to be the axis of relationships with, and care for, these children. The children in this study suffered from a lack of dialogue and explanations that go beyond “It’s for your own good.” This is vague, unsatisfying and uncaring. It is noteworthy that therapeutic play proved to be a resource for listening and care. It should be incorporated into the actions of all those who have the knowledge, preparation and skill to use this methodology. The use of play/toys is recommended practice for nurses. The increased adoption of therapeutic play in pediatric nursing is urgent, and academia must incorporate knowl(11) Matos AP, Canela PC, Silveira AO, Wernet M edge and discussion on this method into nursing training, as well as help provide education in scenarios of care.(5) Based on the results of this study, training courses in health care need to incorporate opportunities to build knowledge and awareness of the experience of chronic illness in young children, as well as among older children and adults, with a view towards more humanized care. Care needs to be designed as a praxis, mutually established among everyone involved: professionals, family members and children. In the absence of construction of care, respect for and appreciation of the autonomy of the children and their families are disregarded. In the present scenario, one wonders whether the relationship of care focuses on the diseases or the children and their families. This seems to be the first variable. Giving voice to children and considering their grievances need to direct health care actions, both in health services and at home.(11,12) Further research that captures the voices of chronically ill children needs to be developed.(13) This study sought to contribute to this effort; however, it only made use of therapeutic play sessions to capture the voices of the children. Other strategies have the potential to broaden understanding of this context, such as integrated use of photographs and interviews. Collaborations Matos APK; Canela PC; Silveira AO and Wernet M participated in the project design, analysis and interpretation of data, important critical review of the intellectual content, and approval of the final version to be published. Conclusion 9. Charon JM. Symbolic Interactionism: an introduction, an interpretation, an integration. 9a ed. Englewoods Cliffs: Prentice Hall; 2007. This study showed that chronically ill children strive to be subjects with rights, yet are conceived of by their social environment as subjects of duties. These children are “depositories” for achieving results, and their social interactions are thus unidirectional and authoritative, under the expectation that they will obey commands. Thus, their voices are almost silenced, and they struggle on a daily basis to be heard, and for their rights as individuals. Acknowledgments Research conducted with support from the São Paulo Research Foundation (FAPESP), process 2010/19723-4. References 1. Leite MF, Gomes IP, Leite MF, Oliveira BRG, Rosin J, Collet N. [Children Chronic condition and hospitalization: the suffering of family caregivers]. Cienc Cuid Saude. 2012;11(1):51-7. 2. Silva MA, Collet N, Silva KL, Moura FM. [The everyday of the family in coping with a chronic condition on infants]. Acta Paul Enferm. 2010;23(3):359-65. Portuguese. 3. Kiche MT, Almeida FA. [Therapeutic toy: strategy for pain management and tension relief during dressing change in children]. Acta Paul Enferm. 2009;22(2):125-30. Portuguese. 4. Morais RC, Machado AA. A utilização do brinquedo terapêutico à criança portadora de neoplasia: a percepção dos familiares. Rev Pesq Cuid Fundam. 2010;(Ed. Supl.):102-6. 5. Maia EB, Ribeiro CA, Borba RI. [Therapeutic toy: benefits observed by nurses in nursing practice focused on the child and the family]. Rev Gaúcha Enferm. 2008;29(1):39-46. Portuguese. 6. Maia EB, Ribeiro CA, Borba RI. [Understanding nurses’ awareness as to the use of therapeutic play in child care]. Rev Esc Enferm USP. 2011;45(4):839-46. Portuguese. 7. Giacomello KJ, Melo LL. [From fantasy to reality: understanding the way of playing of institutionalized children victims of violence through therapeutic play]. Ciênc Saúde Coletiva. 2011;16(1):1571-80. Portuguese. 8. Ribeiro CA, Coutinho RM, Araújo TF, Souza VS. [A world of procedures and worries: Experience of children with a Port-a-Cath]. Acta Paul Enferm. 2009;22(Especial - 70 Anos):935-41. Portuguese. 10.Santos FM. Análise de conteúdo: a visão de Laurence Bardin. Rev Eletrôn Educ [Resenhas]. 2012; 6 (1):383-87. 11. Nóbrega RD, Collet N, Gomes IP, Holanda ER, Araújo YB. [Hospitalized school-age children: the meaning of a chronic condition]. Texto & Contexto Enferm. 2010;19(3):425-33. Portuguese. 12.Coa TF, Pettengill MA. [Children’s autonomy during therapeutic procedures: pediatric nurses’ beliefs and actions]. Acta Paul Enferm. 2006;19(4):433-8. Portuguese. 13.Ångström-Brännström C, Norberg A, Jansson L. Narratives of children with chronic illness about being comforted. J Ped Nurs. 2008;23(4):310-16. 14. Borba RI, Sarti CA. [Infantile asthma and the child’s social and familiar world]. Rev Bras Alerg imunopatol. 2005;28(5): 249- 54. Portuguese. 15. Gabatz RI, Neves ET, Beuter M, Padoin SM. [The meaning of care for children victims of domestic violence]. Esc Anna Nery Rev Enferm. 2010;14(1):135-42. Portuguese. 16. Alexandre DT, Vieira ML. [Attachment relationships among Acta Paul Enferm. 2014; 27(2):126-32. 131 Revelations expressed by preschool children with chronic diseases in outpatient treatment institutionalized children living in a shelter situation]. Psicol Estudo. 2004;9(2):207-17. Portuguese. 17. Melo LL, Valle ER. [The toy library as a possibility to unveil the daily life of children with cancer under outpatient treatment]. Rev Esc Enferm 132 Acta Paul Enferm. 2014; 27(2):126-32. USP. 2010;44(2):517-22. Portuguese. 18.Castro EK, Piccinin CA. [Implications of physical chronic disease in childhood to family relationships: some theoretical questions]. Psicol Reflex Crit. 2002;15(3):625-35. Portuguese. Original Article Level of knowledge, attitudes and practices of puerperal women on HIV infection and its prevention Grau de conhecimento, atitudes e práticas de puérperas sobre a infecção por HIV e sua prevenção Raquel Ferreira Gomes Brasil1 Maysa Mayran Chaves Moreira1 Liana Mara Rocha Teles1 Ana Kelve de Castro Damasceno1 Escolástica Rejane Ferreira Moura1 Keywords Obstetric nursing; Postpartum period; HIV infections; HIV/prevention & control; Acquired immunodeficiency syndrome/ prevention & control Descritores Enfermagem obstétrica; Período pós-parto; Infecções por HIV; HIV/ prevenção & controle; Síndrome de imunodeficiência adquirida/prevenção & controle Submitted December 28, 2013 Accepted April 14, 2014 Corresponding author Raquel Ferreira Gomes Brasil Universidade Avenue, 2853, Fortaleza, CE, Brazil. Zip Code: 60020-181 [email protected] DOI http://dx.doi.org/10.1590/19820194201400024 Abstract Objective: Evaluating the level of knowledge, attitudes and practices of puerperal women on HIV infection and its prevention. Methods: A cross-sectional study with 278 puerperal women hospitalized in the rooming-in system. Interviews were carried out with the use of a questionnaire to evaluate the knowledge, attitudes and practices on HIV infection and its prevention. Results: The age of puerperal women ranged from 13 to 43 years, with prevalence of the range between 20 and 34 years. The level of education between eight and 11 years of studies was predominant, as well as the stable union. Only 54 (19.4%) puerperal women showed adequate knowledge, six showed adequate attitude (2.2%) and four showed appropriate practices (1.4%). Conclusion: The knowledge was inadequate due to the low percentage of puerperal women able to mention at least three ways of transmission and three forms of preventing the virus; inadequate attitude was marked by the high percentage of puerperal women who perceive becoming infected with HIV as ‘unlikely’, and ‘little likely’ that the same occurs with their partners. The inadequate practice was influenced by the low percentage of HIV testing in the recommended periods and the lack of condom use during pregnancy. Resumo Objetivo: Avaliar o grau de conhecimento, atitudes e práticas de puérperas sobre a infecção por HIV e sua prevenção. Métodos: Estudo transversal com 278 puérperas internadas no sistema de alojamento conjunto. Foram realizadas entrevistas com a utilização de um questionário para avaliar o conhecimento, a atitude e a prática sobre a infecção pelo HIV e sua prevenção. Resultados: A idade das puérperas variou de 13 a 43 anos, prevalecendo faixa entre 20 e 34 anos. Predominou escolaridade entre 8 e 11 anos de estudos e união estável. Apenas 54 (19,4%) puérperas apresentaram conhecimento adequado, 6 (2,2%) atitude e 4 (1,4%) práticas adequadas. Conclusão: O conhecimento foi inadequado devido ao baixo percentual de puérperas que souberam citar pelo menos três formas de transmissão e três formas de prevenção do vírus; a atitude inadequada foi marcada pelo elevado percentual de puérperas que percebem como “improvável” infectar-se com o HIV e “pouco provável” o mesmo ocorrer com seu parceiro. A prática inadequada foi influenciada pelo baixo percentual de realização do teste anti-HIV nos períodos preconizados e pelo não uso do preservativo durante a gravidez. Universidade Federal do Ceará, Ceará, CE, Brazil. Conflicts of interest: no conflicts of interest to declare. 1 Acta Paul Enferm. 2014; 27(2):133-7. 133 Level of knowledge, attitudes and practices of puerperal women on HIV infection and its prevention Introduction The infection with the human immunodeficiency virus (HIV) and AIDS are important public health problems in the state of Ceará (northeastern Brazil), in the rest of Brazil and the world, with ascending and pandemic character. The epidemiological profile of HIV/AIDS has undergone changes over the past two decades, no longer affecting only the so-called risk groups, but also beginning to affect men and women in general, observing the heterosexualization, the feminization and impoverishment of the epidemic.(1) As most infected women are of reproductive age, there is particular interest in prevention of vertical transmission of HIV, which can occur during pregnancy, labor, delivery or breastfeeding.(2) Ensuring an effective preconception care is essential to tackle that problem, aiming at knowing the HIV status of the mother, instructing her and providing preventive care against vertical transmission, a policy that depends on the early identification of infected pregnant women to be successful. In addition to preconception care, prenatal care is necessary to prevent virus infection, especially the guidance and advice that must be given before and after HIV testing. The advice is a conduct that requires building mutual trust, establishing a dialogue between professionals and clients, with accessible language, confidentiality and respect for differences and citizenship.(3) The access of pregnant women to HIV testing in ideal time is still problematic, and may happen with delay or not happen at all.(4) Thus, the necessary information about the prevention and detection of HIV should be received in the puerperal period, aiming to prevent vertical transmission. The objective of this study is to assess the level of knowledge, attitudes and practices on HIV infection and its prevention among puerperal women. Methods This is a cross-sectional study with 278 women hospitalized in the rooming-in system of a maternity in 134 Acta Paul Enferm. 2014; 27(2):133-7. Fortaleza, state of Ceará, northeastern Brazil, in the period of November and December, 2011. In this study, knowledge consists in recalling specific facts or having the ability to apply specific facts to solve problems or express concepts with understanding acquired in a particular event; the attitude is essentially, to have opinions, feelings, preconceptions and beliefs that are relatively constant and directed to a target, person or situation; and practice is the decision-making in order to perform an action. The knowledge, attitudes and practices on the prevention of HIV infection were evaluated based on the following selected parameters:(5) -Adequate knowledge: when puerperal women mentioned having heard about HIV, reported at least three forms of virus transmission and at least three forms of prevention. Inadequate knowledge: when puerperal women mentioned never having heard of HIV or having heard of, but not being able to cite at least three appropriate ways of transmission and at least three forms of virus prevention. - Inadequate attitude: when puerperal women recognize that it is unlikely, little likely, or do not have an opinion about them and/or their partner being HIV-infected; when they consider unnecessary, not really necessary or do not have an opinion about health services offering HIV testing, and pregnant women getting tested; when they disregard the need for using condoms in case one partner is HIV positive. - Adequate attitude: when puerperal women recognize that together with their partners, they are individuals susceptible to HIV infection; when they recognize that it is always necessary that health services offer HIV testing and that pregnant women get tested; when they recognize the need to use condoms in case one partner is HIV positive; that they recognize the need for the partner to do an HIV test if pregnant women discover to be HIV positive, and that women are accompanied by a specialized doctor. - Adequate practice: when puerperal women did the HIV test during pregnancy or did the rapid testing in maternity and used condoms in all relationships before the last pregnancy and during the current one. Inadequate practice: when puerperal women did not do the HIV test nor the rapid testing in maternity and did not Brasil RF, Moreira MM, Teles LM, Damasceno AK, Moura ER use condoms in all relationships before pregnancy and after becoming pregnant. In total, 278 puerperal women participated in the survey. The sample size was established based on the population of 1,000 births that occur every two months in the aforementioned maternity. A formula was applied for calculation with finite population, adopting a confidence interval of 95%, maximum possible error of 0.05 and a prevalence of 50% of the phenomenon. Data were collected in interviews, compiled and analyzed using the Statistical Package for the Social Sciences (SPSS), version 11.0 and received descriptive statistical treatment. The development of the study met the national and international standards of ethics in research involving human beings. Results The age of puerperal women ranged between 13 and 43 years; 93 of them (33.5%) were adolescents, aged between 13 and 19 years, 163 (58.6%) were between 20 and 34 years old, and 22 (7.9%) were aged between 35 and 43 years. Hence, the mean age was 23.53±6.67. In total, 200 (71.9%) puerperal women were from the city of Fortaleza and 78 (28.1%) were from the countryside of the state of Ceará. The level of education in years of study was, on average, 8.66±2.55; 71 participants (25.5%) had less than eight years of study and 206 (74.1%) had between eight and 11 years of study. The family income of 152 puerperal women (54.7%) was up to one minimum wage, while 80 (28.8%) reported an income higher than one or up to two minimum wages, and 46 (16.5%) informed an income higher than two minimum wages. Regarding the marital status, 213 (74.7%) declared to be in a stable union or married and 65 (23.4%) were single. Table 1 shows the knowledge of participants about prevention of HIV/AIDS, as well as regarding the sources of information for this knowledge.Table 2 shows the distribution of women according to the attitude towards prevention of HIV infection.Table 3 shows data on practice of prevention of HIV infection. Table 1. Knowledge about the infection with HIV Knowledge n(%) Sources of information TV and/or radio Health professionals School Others Unable to answer 219(78.8) 143(51.4) 126(45.3) 88(31.6) 10(3.6) Forms of transmission 222(79.7) 83(29.9) 47(16.9) 13(4.7) 67(24.1) 46(16.5) Sexual Sharing contaminated needles Blood transfusion Vertical transmission Others Unable to answer Knowledge of preventive measures Avoid unprotected sex Unable to answer Not sharing needles Others 232(83.5) 40(14.4) 35(12.6) 35(12.6) Evaluation of knowledge Adequate Inadequate 4(1.4) 274(98.6) Table 2. Attitude of puerperal women towards prevention of HIV infection Attitude n(%) Probability of women getting infected with HIV Always likely Little likely Unlikely No opinion 73(26.6) 55(19.8) 132(47.5) 18(6.5) Probability of the partner getting infected with HIV Always likely Little likely Unlikely No opinion 65(23.4) 120(43.2) 58(20.9) 35(12.6) Need for HIV testing offered by the service Always necessary Little need Unnecessary No opinion 270(97.1) 2(0.7) 5(1.8) 1(0.4) Need for HIV testing in pregnant women Always necessary Little need Unnecessary No opinion 271(97.5) 5(1.8) 1(0.4) 1(0.4) Need for the partner getting tested if HIV-positive pregnant woman Always necessary Little need Unnecessary No opinion 271(97.5) 1(0.4) 5(1.8) 1(0.4) Necessity to use condoms if HIV-positive partner Always necessary Little need Unnecessary No opinion 272(97.8) 1(0.4) 3(1.1) 2(0.7) Need for specific medical attention if HIV positive pregnant woman Always necessary Unnecessary No opinion 273(98.2) 3(1.1) 2(0.7) Evaluation of atitude Adequate Inadequate 54 (19.4) 224(80.5) Acta Paul Enferm. 2014; 27(2):133-7. 135 Level of knowledge, attitudes and practices of puerperal women on HIV infection and its prevention Table 3. Practice regarding prevention of HIV infection Practices n(%) HIV testing Rapid test in maternity A test during prenatal care out of recommended period Two tests during prenatal care out of recommended period Two tests during prenatal care in recommended period Three tests in prenatal care 100(36.0) 160(57.6) 36(12.9) 23(8.3) 11(4.0) Condom use before pregnancy and its motivations Yes Uses regularly Always uses No Dislikes Is monogamous The partner dislikes Uses another birth control method Others 68(24.6) 47(17) 21(7.6) 210(75.5) 71(25.5) 52(18.7) 47(16.9) 29(10.4) 11(4.0) Condom use during pregnancy and its motivations Yes Used regularly Always used No Dislikes Monogamous Sexual partner does not like No need for contraception In sexual abstinence during pregnancy Others 24(8.6) 17(6.1) 7(2.5) 254(91.3) 73(26.3) 65(23.4) 47(16.9) 29(10.4) 29(10.4) 11(3.9) Evaluation of practice Adequate Inadequate 7(2.2) 271(97.8) Discussion The limits of the results of this study refer to the cross-sectional design that does not allow establishing relations of cause and effect. The most prevalent age ranged from 20 to 34 years, as expected, since the range corresponds to period of time in which the largest number of pregnancies occur. However, the high percentage of pregnant adolescents (33.5%) stands out, as well as the high number of pregnancies in the end of reproductive age (7.9%). The majority (71.9%) came from the city where the study was carried out and the others were from the countryside of the state, and referred to the maternity due to the risk associated with childbirth. Most puerperal women reported a level of education between eight and 11 years of study. This result was also reported on a study carried out in the State of Rio de Janeiro, southeastern Brazil.(6) Thus, the two contexts revealed a low level of education among participants (users), which may indicate poor information regarding the rights and duties when it comes to health, making them more vulnerable to diseases. 136 Acta Paul Enferm. 2014; 27(2):133-7. Approximately 54.7% of puerperal women had an income of up to a minimum wage. In this sense, the authors state that women, especially those with less purchasing power, have greater impairment of health and succumb to HIV infection more quickly than men.(7) The marital status of married or in stable union was predominant, accounting for 165 (59.4%) puerperal women, a favorable aspect to the exercise of a safe motherhood, as these are women sharing the same residence with their partners and also the same feelings of complicity and companionship.(1) The instruction of participants on prevention of HIV infection revealed that four (1.4%) had adequate knowledge, i.e. although the majority had heard about the infection, knew some form of transmission and the care to prevent it, they were not able to mention at least three ways of transmission and three forms of prevention. Not unlike this Brazilian reality, a study carried out in Nigeria with 172 pregnant women about the knowledge, attitudes and practices focused on the prevention of HIV infection, found that 61.6% of participants believed that the infection was caused by a virus, while 44 2% reported it was a punishment from God, and 3.5% stated it was the result of witchcraft. Therefore, in the study carried out in the African country, it is observed that myths linked to religiosity must be overcome.(5) In face of this scenario, it was found that the information provided during the prenatal care must include the approach on prevention of HIV infection, emphasizing the need for HIV testing and the adoption of specific measures to prevent vertical transmission. The percentage of inadequate knowledge detected in the studied group of puerperal women indicates failure in health education. It is noteworthy however, that the attitude of 54 interviewed women (19.4%) regarding the prevention of HIV infection was adequate, while six (2.2%) showed adequate practice. In the present study, a finding that deserves attention in relation to the practice of puerperal women, concerns the four women who reported not using condoms during pregnancy for believing that during this period of the reproductive cycle it was impossible to contract the disease. This leads again, to a reflection Brasil RF, Moreira MM, Teles LM, Damasceno AK, Moura ER on the importance of health education in nursing care during the puerperal cycle. Considering the lack of HIV testing and/or rapid testing by a portion of the surveyed pregnant women, it is possible to conclude that the information provided to this population might be insufficient. However, the unavailability of exams in antenatal services and maternity hospitals is also questioned. It is considered that the nursing team has the important action to promote changes in knowledge, attitude and practices of women. Conclusion The knowledge was inadequate due to the low percentage of puerperal women who were able to mention at least three ways of transmission and three forms of preventing the virus; the inadequate attitude was marked by a high percentage of puerperal women who perceive becoming infected with HIV as ‘unlikely’ and ‘little likely’ that the same occurs with their partners. The inadequate practice was influenced by the low percentage of HIV testing in the recommended periods and the lack of condom use during pregnancy. Collaborations Brasil RFG collaborated with 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. Moreira MMC contributed to the analysis and interpretation of data. Teles LMR and Damasceno AKC participated in the project design. Moura ERF collaborated in writing the article, critical revision of the important intellectual content and final approval of the version to be published. References 1. Maia C, Guilhem D, Freitas D. [Vulnerability to HIV/AIDS in married heterosexual people or people in a common-law marriage]. Rev. Saúde Pública. 2008;42(4):242-8. Portuguese. 2. Gonçalves VL, Troiani C, Ribeiro AA, Spir PR, Gushiken EK, Vieira RB, Prestes-Carneiro LE. [Vertical transmission of HIV-1 in the western region of the State of São Paulo]. Rev Soc Bras Med Trop. 2011;44 (1):4-7. Portuguese. 3. Fonseca PL, Iriart JA. Aconselhamento em DST/Aids às gestantes que realizaram o teste anti-HIV na admissão para o parto: os sentidos de uma prática. Interface (Botucatu). 2012;16(41):395-407. 4. Veloso VG, Portela MC, Vasconcelos MT, Matzenbacher LA, Vasconcelos AL, Grinsztejn B, Bastos FI. HIV testing among pregnant women in Brazil: rates and predictors. Rev Saúde Pública. 2008;42(5): 859-67. 5. Moses CC, Udo S, Omotora B. Knowledge, attitude and practice of ante-natal attendees toward prevention of mother to child transmission (PMTCT) of hiv infection in a tertiary health facility, Northeast-Nigeria. East Afr J Public Health. 2009;6(2):128-35. 6. Albuquerque VS, Moco ET, Batista CS. [Black Women and HIV: determinants of vulnerability in the mountainous region of the state of Rio de Janeiro]. Saúde Soc. 2010;19(2):63-74.Portuguese. 7. Okuno MF, Souza FD, Assayag BR, Aparecida BD, Silva BA. Knowledge and attitudes about sexuality in the elderly with HIV/AIDS. Acta Paul Enferm. 2012;25(Spec 1):115-21. Acta Paul Enferm. 2014; 27(2):133-7. 137 Original Article Opinion of nursing students on realistic simulation and the curriculum internship in hospital setting Opinião dos estudantes de enfermagem sobre a simulação realística e o estágio curricular em cenário hospitalar Alessandra Freire Medina Valadares1 Marcia Cristina da Silva Magro1 Keywords Simulation; Education, nursing/ methods; Students, nursing; Computerassisted instruction; Education, nursing, baccalaureate/methods Descritores Simulação; Educação em enfermagem/ métodos; Estudantes de enfermagem; Instrução assistida por computador; Bacharelado em Enfermagem/métodos Submitted January 29, 2014 Accepted March 26, 2014 Corresponding author Marcia Cristina da Silva Magro Campus Ceilândia-Universidade de Brasília, Brasília, DF, Brazil. Zip Code: 70910-900 [email protected] DOI http://dx.doi.org/10.1590/19820194201400025 138 Acta Paul Enferm. 2014; 27(2):138-43. Abstract Objective: Comparing the opinion of undergraduate nursing students about the realistic simulation and the curricular internship in a hospital setting. Methods: A comparative study with 55 nursing students who were divided into a control group that did a curriculum internship in a hospital setting, and an experimental group that participated of a realistic simulation prior to the hospital setting. Both groups answered an instrument based on the Likert scale to verify the effectiveness of the two teaching strategies. Results: In the experimental group, 69 % totally agreed that the simulation consolidated the teaching-learning process. In the control group, most students (38.5 %) totally disagreed with the internship in the hospital setting as an isolated strategy. Conclusion: In the opinion of nursing students, the realistic simulation was effective to acquire and refine knowledge and security, in addition to develop critical thinking in face of the common routine clinical situations in nursing care practice. Resumo Objetivo: Comparar a opinião dos estudantes de graduação em enfermagem sobre a simulação realística e sobre o estágio curricular em cenário hospitalar. Métodos: Estudo comparativo realizado com 55 estudantes de enfermagem, divididos em: grupo controle que realizou estágio curricular em cenário hospitalar e grupo experimental realizou simulação realística antes do cenário hospitalar. Ambos os grupos responderam um instrumento baseado na escala de Likert para verificação da efetividade das duas estratégias de ensino. Resultados: No grupo experimental, 69,0% concordaram totalmente que a simulação consolidava o processo de ensino-aprendizagem. No grupo controle, muitos estudantes (38,5%) discordaram totalmente com o estágio em cenário hospitalar como estratégia isolada. Conclusão: A simulação realística foi efetiva na opinião dos estudantes de enfermagem para adquirir e aperfeiçoar conhecimentos e segurança, além de desenvolver o raciocínio crítico frente às situações clínicas comuns ao cotidiano da prática assistencial do enfermeiro. Faculdade de Ceilândia, Universidade de Brasília, Brasília, DF, Brazil. Conflicts of interest: no conflicts of interest to declare. 1 Valadares AF, Magro MC Introduction High fidelity simulation is an educational tool capable of mimicking real clinical situations in a safe environment, and it allows that nursing students cognitively develop, as well as developing attitudinal and psychomotor clinical skills/competences.(1) The simulation is a teaching method with the application of learning exercises that mimic real-life situations. The development of a theoretical framework based on scenarios and care guidelines for nurses is an important step in reshaping nursing education.(2) The implementation of the simulation allows students to practice and correct their mistakes in situations of clinical routine, without risks to patients and with minimal risk to themselves.(3) The simulation allows the improvement of the performance of students from their own mistakes, learning from failures until getting it right, which is unacceptable practice in a real situation.(4,5) The simulation is recommended for student assessment, development and exchange of ideas, teamwork and team leadership, creative thinking and problem solving - situations that ultimately focus on motivation.(1,6,7) The aim of this study was to compare the views of undergraduate nursing students about the realistic simulation and the curricular internship in a hospital setting. Methods This is a comparative, prospective study carried out with 55 undergraduate nursing students in the Laboratory of Skills of Care of the Faculty of Ceilândia, in the Universidade de Brasília. Students enrolled in the seventh, eighth or ninth semester of the nursing course were included in the study. Were excluded those who had not attended the courses “Adult health” and “Nursing care for critical and risk patients”. Students were divided into two groups: experimental and control. The control group did an internship in a hospital setting and attended lectures. The experimental group also did an internship and attended lectures, but with application of the simulation strategy before the internship program. The experimental group was divided into subgroups consisting of five students to allow effective observation and debriefing (discussion) among all students and the teacher on the subject addressed in the simulation. The simulation was implemented during a week prior to the internship, using the SimMan® patient simulator connected to a heart monitor and reproducing the vital signs, physiological findings such as heart rate, breath sounds, palpable pulse, among others, in real time. The simulator reproduces sounds and responses to questions by the control of an operator, teacher of the course. Different clinical cases were used, which allowed the reproduction of objective and consistent situations in real time. During the simulation the participating student was able to call the patient’s family and experts (played by the teacher and monitors) immediately, request spreadsheets with laboratory and radiological findings as deemed necessary, in order to promote spontaneity and reality to the proposed situation. In order to maintain uniformity and realism among the different scenarios of operation, each participant was given 15 minutes to perform, after which the students in the experimental group (simulation), conducted by the teacher, gathered in the laboratory to discuss best practices, conflicts and issues related to self-confidence of students during the activities. Students in the experimental group completed an instrument based on the Likert scale to verify the effectiveness of the strategy of realistic simulation as a vehicle to acquire and refine knowledge and security, and to develop critical and clinical thinking in face of common clinical situations in the daily care practice of nurses. The control group filled out the same instrument, in which they expressed the influence of traditional pedagogical strategy to ensure a safe performance and the development of clinical and critical thinking in patient care. Acta Paul Enferm. 2014; 27(2):138-43. 139 Opinion of nursing students on realistic simulation and the curriculum internship in hospital setting All data were expressed as mean and standard deviation for quantitative variables, and as absolute and relative frequencies for qualitative variables. For statistical analysis and comparison between different groups, the Mann-Whitney test was used. In this analysis, the responses to the questions were represented by categories corresponding to values from one to five as follows: one as totally disagree, two as partially disagree, three as neutral, four as partially agree and five as totally agree. The development of the study met the national and international standards of ethics in research involving human beings. According to the two groups, both strategies (simulation and internship) were relevant tools in the teaching-learning process. Hence, it was not possible to identify a statistically significant difference (p=0.1) between the approaches. It is noteworthy that 51.7% said that the simulation should be implemented in the teaching-learning process due to broadening the relationships between teachers, students and patients; 58.6% considered this strategy a good tool for the more active development of autonomy; 76.9% stated that simulation promoted exposure to real clinical situations in a simulated and safe environment as the laboratory; and 55.2% affirmed that it has minimized damage to patients during care in the hospital setting (real). In the control group, 31.2% of students stated that one of the main difficulties was coping with the insecurity in face of patients, followed by the lack of independence for care activities (25%). In this group, a minority (6.2%) reported that the main difficulties were to apply the newly learned techniques directly to patients, the lack of temporal parity between practice and theory, the exposure to situations that had not been studied yet, and the reduced time of internship. The predominant advantages reported by students in the control group were the experience of the hospital reality even without the ad- Results A total of 55 students were accompanied, predominantly female and in the seventh semester, with a mean age of 22 years. In the experimental group, most students (69%) totally agreed that this strategy consolidated the teaching-learning process and 27% partially agreed with this. In addition, 44.8% totally agreed with the isolated use of this strategy in the curricular grid and 20.7% partially agreed. In the group without simulation 38.5% of participants totally disagreed that the internship should be kept as a curricular strategy alone (Figure 1). 14 44.8% 12 10 38.5% 8 20.7% 6 4 13.8% 6.9% 2 19.2% 15.4% 15.4% 13.8% 11.5% 0 Totally Disagree Partially Disagree With Simulation Neutral Partially Agree Without Simulation Figure 1. Opinion regarding the use of simulation as an isolated curricular strategy 140 Acta Paul Enferm. 2014; 27(2):138-43. Totally Agree Valadares AF, Magro MC equate contribution (37.5%), correlation of theory with practice (31.2%), exposure to different cases (25%) and only a minority (6.2%) stated that the internship isolatedly allowed the elaboration of critical thinking. In the experimental group, on its turn, the results showed that 33.3% of students considered the lack of time and space to implement the simulation one of the greatest difficulties; 16.7% cited few practices and little access to the lab. Moreover, the exacerbation of anxiety triggered by the implementation of an active/participatory evaluation, the lack of adequate physical infrastructure and the excessive number of students in classes (11.1%) were also considered limiting factors. Still from this perspective, a minority of students (5.6%) cited as difficulties faced in the implementation of high fidelity simulation, the high cost and the resistance of some professionals to accept the simulation as an effective practical strategy, as well as the insecurity and fear of adopting the wrong procedures. In this group it was also found that the simulation has improved practice and theory (35%), produced greater confidence and safety during care (25%), developed agility and critical thinking (15%), allowed better interaction with the group and contact with various clinical situations (10%). Only 5% of the students mentioned that through the simulation strategy it was possible to experience situations that required more speed and agility from professionals. As a suggestion, 81% of students indicated the need for extensive use of simulation throughout the semester together with lectures. In addition, 14.2% suggested adding the simulation in all disciplines (basic and specific) and 4.8% reinforced the need for a specific location to implement this strategy. Discussion The limitations of this study are related primarily to the sample size, because it was carried out in a single institution. The contribution of this study results are the new possibilities of knowledge acquisition, through a participative and realistic methodology that enables the learning itself, adding knowledge in the training process of the student. The quality of care allied to patient safety demanded by citizens, requires higher professional qualifications, skills and safety to promote the welfare desired by the population. Over the years, the high fidelity simulation has achieved consistency as an educational and training tool for the academic education and health professionals.(8) The scientific evidence reveals this is an important, innovative and complementary strategy that should be incorporated into the curriculum grid in order to consolidate and optimize the teaching- learning process of students.(4) Practices involving simulation should be planned respecting the complexity of the scenarios of operation and the demands, in a way that students can gradually acquire the skills.(9) Although students consider that this strategy can be adopted solely, studies recommend the integration of simulation in the learning environment as a support and complementary tool, allowing reasonable adjustments of students’ skills in a systematic way. This process develops the capacity to perform, promote wellness, alleviate risks and ensure the safety of all involved.(1,10) Students recognize the simulation and curriculum internship as practices that, when combined, broadly contribute to training and the opportunity to mix modalities that enrich and consolidate learning.(11) The contact of students with an innovative situation can create tensions and interfere with the learning process.(12) However, the participation in simulation scenarios promotes mainly the learning and improvement of critical thinking.(13) In this direction, recent systematic reviews have highlighted the use of this strategy as a vehicle for knowledge acquisition and early identification of deterioration of patients.(14,15) The simulation, if appropriately integrated, can be used in academic environments as an active learning methodology that provides advantages for the group of students, such as possibility of adapting theory into practice, greater confidence Acta Paul Enferm. 2014; 27(2):138-43. 141 Opinion of nursing students on realistic simulation and the curriculum internship in hospital setting and security in clinical practice, development of agility and critical thinking, in addition to allowing team interaction and enhancing the clinical experience from various clinical situations. In contrast, it was found that the curriculum internship isolated, exposes students to cope with the insecurity and lack of independence to act, and makes them apply newly learned techniques directly into patients without previous training. In simulation activities, students have the opportunity to make mistakes, improve techniques and adopt procedures without fear of damages, considering the lab practices as a transition to reality in care. Thus, from the simulation experiments, it is believed that there is a reduction of errors in procedures in clinical situations identified from a continuum of action with reflection in the nursing process, a condition reinforced by the simulation group.(16) However, the learning subsidized by the simulation has clear synergies with the curriculum of the nursing program and consistency with the educational intent of our times. As nursing is a practical profession, it presupposes competence in a number of predominantly psychomotor skills, and it needs to provide strategies for students that combine the act of caring with the theoretical-scientific framework of the classroom. A high fidelity simulation enhances the teaching-learning process, due to the fact of being a relevant teaching strategy, which can be implemented in the curriculum grid to consolidate this process and expand the competencies and skills of students. Moreover, it contributes significantly when aggregated to a curriculum internship program. The results suggest that the use of simulation actively develops the abilities of clinical reasoning and critical thinking, enabling a safe practice, minimizing risks and improving students’ performance in face of patients. 142 edge and security, in addition to develop critical thinking in face of the common routine clinical situations in nursing care practice. Acknowledgements Research carried out with the support of the Conselho Nacional de Desenvolvimento Científico e Tecnológico – CNPq, under process no 162370/2012-1. Collaborations Valadares AFM participated in the project design, data collection and interpretation of data and writing of the article. Magro MCS contributed to the project design and planning, data interpretation, drafting and critical review of the relevant intellectual content, and approval of the final version to be published. References 1. Bland AJ, Topping A, Wood B. A concept analysis of simulation as a learning strategy in the education of undergraduate nursing students. Nurse Educ Today. 2011;31(7):664-70. 2. Waxman KT. The development of evidence-based clinical simulation scenarios: guidelines for nurse educators. J Nurs Educ. 2010;49(1):29-35. 3. McCaughey CS, Traynor MK. The role of simulation in nurse education. Nurse Educ Today. 2010;30(8):827-32. 4. Kardong-Edgren SE, Starkweather AR, Ward LD. The integration of simulation into a clinical foundations of nursing course: student and faculty perspectives. Int J Nurs Educ Scholarsh. 2008;5: Article 26. 5. Berragan L. Simulation: an effective pedagogical approach for nursing? Nurse Educ Today. 2011;31(7):660-3. 6. Ricketts B. The role of simulation for learning within pre registration nursing education - a literature review. Nurse Educ Today. 2011;31(7):650-4. 7. Shapira-Lishchinsky O. Simulations in nursing practice: toward authentic leadership. J Nurs Manag. 2014; 22(1):60-9. 8. Patow CA. Advancing medical education and patient safety through simulation learning. Patient safety & quality Healthcare [Internet]. 2005 [cited 2013 Nov 21]. Available from http://www.psqh.com/marapr05/ simulation.html. 9. Wall BM. Religion and gender in a men’s hospital and school of nursing, 1866-1969. Nurs Res. 2009;58(3):158-165. Conclusion 10. Khalaila R. Simulation in nursing education: An evaluation of students’ outcomes at their first clinical practice combined with simulations. Nurse Educ Today. 2014;34(2):252-8. In the opinion of nursing students, the realistic simulation was effective to acquire and refine knowl- 11.Cardoza MP, Hood PA. Comparative study of baccalaureate nursing student self-efficacy before and after simulation. Comput Inform Nurs. 2012;30(3):142-7. Acta Paul Enferm. 2014; 27(2):138-43. Valadares AF, Magro MC 12.Szpak JL, Kameg KM. Simulation decreases nursing student anxiety prior to communication with mentally ill patients. Clinical Simulation in Nursing. 2013;9(1):e13-9. 13. Guhde J. Using online exercises and patient simulation to improve students’ clinical decision-making. Nurs Educ Perspect. 2010;31(6):387-9. 14. Lapkin S, Levett-Jones T, Bellchambers H, Fernandez R. Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: a systematic review. Clin Simul Nurs. 2010;6(6):e207-22. 15.Harder BN. Use of simulation in teaching and learning in health sciences: a systematic review. J Nurs Educ. 2010;49(1):23-8. 16.Kaddoura MA. New graduate nurses’ perceptions of the effects of clinical simulation on their critical thinking, learning, and confidence. J Contin Educ Nurs. 2010;41(11):506-16. Acta Paul Enferm. 2014; 27(2):138-43. 143 Original Article Contamination rate of blood tests and its determining factors Taxa de contaminação de testes hematológicos e seus fatores determinantes José Enrique De La Rubia-Ortí1 Gemma Verdu-Trescolí2 Vicente Prado-Gascó1 Pablo Selvi-Sabater3 Joao Firmino-Canhoto1 Keywords Contamination; Hematologic tests/ blood; Hematologic tests /nursing; Blood/microbiology Descritores Contaminação; Testes hematológicos/ sangue;Testes hematológicos/ enfermagem; Sangue/microbiologia Submitted February 7, 2014 Accepted March 26, 2014 Abstract Objective: Determining the contamination rate of blood cultures and its determining factors. Methods: During a period of six months, were analyzed 564 blood culture samples requested at hospital emergency wards and 46 nurses were inquired. Results: In a period of six months, among a total of 564 requests, 92 blood cultures were contaminated, which corresponds to a contamination rate of 16.31%. The determining factor was the use of low-level sterile technique. Conclusion: The contamination rate of blood cultures is directly related to the procedures used by the nursing staff, and the workload is directly related to errors in the sterile technique of collection. Resumo Objetivo: Conhecer a taxa de contaminação de hemoculturas e os seus fatores determinantes. Métodos: Foram analisadas 564 amostras de hemoculturas requisitadas num serviço hospitalar de urgências e questionados 46 enfermeiras(os) durante um período de seis meses. Resultados: Produziram-se 92 contaminações de hemoculturas de um total de 564 requisições num período de seis meses, o que corresponde a uma taxa de contaminação de 16,31%. O fator determinante foi a utilização de técnica pouco estéril. Conclusão: A taxa de contaminação das hemoculturas está diretamente relacionada aos procedimentos utilizados pelos profissionais de enfermagem e a carga de trabalho está diretamente associada a erros na técnica estéril de coleta. Corresponding author José Enrique De La Rubia Ortí Calle General Elio 8, 46010, Valencia, Spain. [email protected] Universidade Europeia de Valência, Valencia, Spain. Universidade Católica de Valência, Valencia, Spain. 3 Hospital Morales Meseguer, Murcia, Spain. Conflicts of interest: no conflicts of interest to declare. 1 DOI http://dx.doi.org/10.1590/19820194201400026 144 Acta Paul Enferm. 2014; 27(2):144-50. 2 De La Rubia-Ortí JE, Verdu-Trescolí G, Prado-Gascó V, Selvi-Sabater P, Firmino-Canhoto J Introduction Among the various diagnostic tests that take place in emergency services, the blood cultures stand out. It is a diagnostic tool used to isolate, detect and identify the microorganisms present in the blood, for further observation of their susceptibility in order to choose the appropriate treatment. (1-3) Contamination of blood cultures is a frequent problem in any hospital. A blood culture is considered to be contaminated if the presence of the following microorganisms is observed in 50% of all blood culture kits extracted in a day from a patient: S. coagulase-negative, alpha-hemolytic Streptococcus, Micrococcus species, Propionibacterium species, Corynebacterium species and Bacillus species.(4-6) According to the American Society for Microbiology the contamination levels of samples should not exceed 3%, although they frequently exceed 7%.(7) The suppression of false positives to the highest possible extent is a measure of great impact, since this could prevent the realization of additional testing, the administration of possibly unnecessary medication, and increase the hospital stay of patients, implying an important finance expense.(5,8-10) The main cause of contamination is linked to manipulation by the nursing staff, especially in hospital services with a large workload and limited time to work with each patient.(11) Following are highlighted some of the most relevant factors related to the practice itself, according to the literature. Regarding the collection technique, each protocol differently emphasizes some predictable factors that contribute to the lack of sterility of the sample. A contributing factor is the effectiveness of the antiseptic used, which is defined as the drug of nonspecific action and strictly external use that is capable of destroying or inhibiting the growth of microorganisms living or temporarily present on the skin or mucous membranes.(12,13) In addition to its composition, antiseptics are different due to its speed and residual effect. The effectiveness of any antiseptic is related to the waiting time of drying.(8) Studies were also published about this data, specifying that the tincture of iodine acts 30 seconds after applying, while povidone iodine needs two minutes. Regarding the biguanides, the 2% aqueous chlorhexidine requires a time close to two minutes, and the alcoholic based chlorhexidine needs 15-30 seconds.(14) In any case it seems that this (alcoholic based chlorhexidine) is more effective than alcohol and povidone iodine when it comes to reducing the number of contaminated samples.(8,9) In this sense, a combination of chlorhexidine and 70% isopropyl alcohol (ChloraPrep®) could reduce the rate of contamination of blood cultures even more.(14,15) The use of sterile gloves influences the amount of contamination and reduces the number of microorganisms responsible for the creation of false positives by up to 50%.(16,17) Its use should be reduced to the moments prior to preparation of the patient’s skin, i.e. the location of the point of puncture and cleaning of the skin. Sterile gloves should be used from the waiting time of drying the antiseptic to reduce the risk of contamination of fluids due to the presence of microorganisms on the skin of professionals.(2) Regarding the amount of blood extracted by tube, with at least 10 ml, between 90 and 95% of microorganisms are obtained, although the current recommendations are 20 ml per tube.(1,2,7) Our hypothesis is that contamination of blood cultures in a hospital is higher than we thought, and that it happens in the emergency service in particular, where rushing in carrying out diagnostic tests and taking medical decisions presumably hinders the following of established protocols at the same time that it increases the percentage of mistakes, and therefore also increases the percentage of infected cultures. The aim of this study was to determine the contamination rate of blood cultures and its determining factors. Methods This is a descriptive observational and mixed study carried out at the Hospital Lluís Alcanyís, located in Xàtiva, in the city of Valencia, Spain. Acta Paul Enferm. 2014; 27(2):144-50. 145 Contamination rate of blood tests and its determining factors Between the months of October 2012 and March 2013 were studied 564 blood cultures collected in the emergency department. In this period, 46 nurses of service agreed to participate. The method of intentional cluster sampling was used. Most professionals of the emergency service were women (74%), aged between 35 and 50 years. Regarding the time since graduation, 52% had between 11 to 20 years, 32.6% over 20 years, 13% between 5-10 years and 2.2% less than five years. Two methodologies were used to obtain the study data: on the one hand, the contaminated samples were detected, and on the other hand was designed an ad-hoc survey from the data of the protocol for blood cultures collection and predisposing factors for contamination. The nursing staff from emergency working under a formal contract was included in the study. On the arranged dates they participated in the survey on techniques and knowledge for collection of blood culture. Were excluded from the study the nurses to whom the questionnaire was presented and decided not to participate, and professionals unable to participate in the questionnaire due to sickness leave. Similarly, were eliminated blood cultures collected on emergency after the study period, and samples of doubtful contamination according to the criteria of the microbiology staff. The survey was available on paper form and online, created with Google Docs. The paper questionnaire was given to professionals in person, along with an envelope to ensure anonymity. The online questionnaire was sent by email to the professionals who did not work in the center. The information for detecting contaminated samples was obtained from file access to samples of the microbiology service via GestLab® software by conducting a search for positive samples analyzed in the period from October 2012 to March 2013 with aerobic and anaerobic tubes; inspecting the data of positive blood cultures according to the microorganism; reviewing the positive samples infected with S. Epidermidis, S. coagulase-negative, S. hominis, Corynebacterium spp., Staphylococcus spp., P. spp., Corynebacterium matruchotii and Micrococcus luteus, to assess 146 Acta Paul Enferm. 2014; 27(2):144-50. possible contamination; organizing the data by month and day of week and evaluating the origin of the samples in order to focus the study only on emergency service. The questionnaire comprised of 15 questions, divided in two parts: in the first part was collected sociodemographic information (age, gender, time since graduation), and in the second part was collected information about the knowledge of nurses regarding the following of sample collection protocols (use of gloves, disinfection of skin, number of needles used, drying time, handling of vials). The study was carried out from October to March due to the possible lack of data about professionals that were on holidays in periods prior to the start month. However, most of the sample was composed of the regular professional staff of the service. The survey period coincided with the final dates of the study period, in which were evaluated the techniques used by staff throughout the study period. Statistical analysis was performed using the SPSS 20.0®. First were calculated the most important descriptive statistics for the study variables and then it was determined if there were differences in the studied variables in relation to gender. The percentages and graphs of qualitative variables as well as data on contaminated blood cultures were obtained by Excel®. The development of study followed the national and international standards of ethics in research involving human beings. Results There were 564 requests for samples, among which 92 were contaminated, i.e. 16.31% of the requested samples. Following, are exposed the samples and its contamination in relation to the months of the study (Table 1). October was the month with the highest number of contaminations (23.85%) and January the month with the lowest proportion of contaminated samples (9.85%). De La Rubia-Ortí JE, Verdu-Trescolí G, Prado-Gascó V, Selvi-Sabater P, Firmino-Canhoto J Table 1. Requests for blood cultures, contamination and percentage of contamination by month Month Requests Contamination nº Contamination % October 109 26 23.85 November 33 7 21.21 December 110 19 17.27 January 71 7 9.85 February 181 27 14.91 March 60 6 10 Total 564 92 16.31 Concerning the comparison of contaminated samples in relation to the type of contaminating bacteria (Figure 1), mostly aerobic bacteria were the causative, especially in October, and except for February, when the percentage of contamination by anaerobic bacteria was higher. As for the day of the week with more records of contamination, Mondays stand out as the days in which, after analysis, the largest number of samples was contaminated. In this aspect, there were 25 records of contaminated samples on Mondays, 15 on Tuesdays, 17 on Wednesdays, 19 on Thursdays and 16 on Fridays. With regard to the knowledge of nurses on collection protocols, 84% of them reported knowing all the steps to properly collect blood cultures, against 8.7% that admitted not to have this knowledge. The following factors were examined in relation to the protocols: frequency of handwashing, use of sterile techniques, contact with the area of venipuncture, number of needles used, respect for drying time, cleaning during the procedure, antiseptic cleaning of vials and skin, compression before or after the needle extraction, the volume of blood drawn per vial, extraction from existing catheters. Considering the frequency of handwashing, 57% of nurses reported always washing their hands before collection, 39% said to do it occasionally and 2.2% reported never doing it. Regarding the use of sterile techniques, much of the nursing staff admitted not using sterile techniques (76%) for the collection of blood culture samples. The main reason for that was the reduced availability of the service (60%) or to a lesser extent, the lack of technique (6.5%). Most nurses reported touching the area of venipuncture to find a vein (30.4%) after disinfecting the area. When considering the number of needles used in the procedure of collection of blood cultures, 50% of the professionals often use devices directly from the patient to the vial, 26% admitted using two needles for extraction, 20% used a needle for everything and only 4% used more than two needles. Most respondents reported to respect the waiting time required for drying the antiseptic before carrying out the procedure/technique (67.4%). Analyzing the cleaning during the procedure, 37% of professionals admitted not using any antiseptic for the cleaning of vial. On the other hand, 34.8% reported using a gauze with antiseptic for each vial and 23.9% reported to use the same gauze 20 15 10 Aerobic Anaerobic 5 0 October November December January February March Figure 1. Comparison of contaminated samples by month and aerobic and anaerobic microorganisms Acta Paul Enferm. 2014; 27(2):144-50. 147 Contamination rate of blood tests and its determining factors for two vials. Among those who used some antiseptic, a large percentage of professionals cleaned the vial with iodine (35%), a minimum percentage used chlorhexidine (4%) and 26% used alcohol. The most widely used antiseptics for cleansing the skin are iodine (46%) and alcohol (43%) and the less used is chlorhexidine (11%). A greater number of professionals reported extracting the needle before compressing the venipuncture zone (63%) compared to 30.4% who informed to compress on the needle. Most professionals (67.4%) collected about 10 ml of blood to inoculate 5 ml per vial, compared to those who extracted 20 ml (17.4%) and other quantities (15.2%). A high percentage of nurses collected blood from existing catheters in patients to do blood cultures (58%), compared to 2% who indicated always doing it and 39% who said they never did it. Discussion After analyzing the study data, the first information that stands out is that the contamination percentages in October, December and February show a directly proportional relationship with the number of blood cultures requests per month and the number of contamination of the samples, except for November. After separating the blood culture vials in aerobic and anaerobic, the percentage of contamination of the first turned out to be significantly higher, which demonstrates a predisposition for an easier contamination. As stated in similar studies, the amount of blood inoculated into each vial influences its contamination, and insufficient or excessive inoculation could increase the presence of contaminants and lead to false positives.(8) In the case of a significant majority of aerobic contaminants, the explanation that best fits is the filling of aerobic vials at first, following the BACTEC® guidelines, although if aseptic conditions or management of fluids were not appropriate, this would lead to microorganisms presence in greater numbers in the first inoculation. 148 Acta Paul Enferm. 2014; 27(2):144-50. Regarding the relation between the contamination according to the day of the week, most of contaminated blood culture vials were detected on Mondays, which can be explained because a large percentage of samples was collected between Friday and Sunday, and the lab remained closed during this period. Blood culture samples collected in the emergency room showed high levels of contamination. These data demonstrate a relationship between the workload of nursing staff and the samples ending up contaminated, which is in agreement with other studies.(11) The contamination rate of 16.31% far exceeds the 3% recommended by the American Society of Microbiologists and the 7% that occurs in other types of services. After organizing professionals by age and time since graduation, it is possible to establish a relationship between the experience as nurses and the grade of knowledge on the collection technique. Despite the experience of the professionals, half of the inquired sample stated to wash their hands before the extraction procedure at all times, but not with an antiseptic, although these are the recommendations.(3,6) In relation to the sterile technique, the studied professionals admitted to use sterile gloves, but not to use a sterile cloth for placing the material used for blood cultures collection because this recommendation is not in the procedure protocol of the center. Most reported not using a sterile technique, and this data was obtained in other studies too.(11) The study predicted that the main reason for not using a sterile technique was the workload. However, a minor percentage was not familiar with the technique or unaware of the protocol. In order to evaluate the sterility of the extracted fluid it was observed that a large percentage of the professionals touched the venipuncture area again after disinfecting the skin of the patient, a fact that increases contamination.(1-3,8,16) Regarding the number of needles used, no significant results were obtained. According to the reviewed bibliography, the single-needle with pre-attached holder (Vacutainer®) is considered to increase the inoculation sterility of the tubes and reduce the De La Rubia-Ortí JE, Verdu-Trescolí G, Prado-Gascó V, Selvi-Sabater P, Firmino-Canhoto J risk for professionals.(11) This data is favored by this study results since 50% of professionals admitted using a device directly from patients to the blood culture vial (Vacutainer®, intravenous catheter with obturator cap). Regarding the tubes closure, the protocol of the center recommends cleaning the lids but does not emphasize which compound should be used for disinfection. However, the recommendations of inoculation of the BACTEC® devices suggest the use of ethanol, what is also supported in another study that used alcohol 70%.(17) In this study, most professionals reported to use iodine compounds for disinfection of the lids. In this sense, another study suggests stop using chlorhexidine or iodine compounds on the tube lids since it may damage the septum.(4) In contrast, another study claims that it is not necessary to disinfect the tube lids since they are open in a sterile manner and need not to be cleaned.(10) As for the disinfection of the skin of patients, iodine was used mainly prior to venipuncture. On the other hand, some studies indicate chlorhexidine as the antiseptic of excellence.(4) A large majority of respondents admitted extracting 10ml of blood per patient to inoculate 5 ml in each tube, which may have changed the number of positive samples once an amount of less than 8 or 10ml per tube might not be sufficient to detect one bacteremia. Most professionals reported to occasionally obtain samples from venous catheters, despite the protocol emphasizing that blood should not be extracted from intravenous catheters under any circumstances, as corroborated by other studies,(6) unless in the case of suspected bacteremia associated with a microorganism present in the intravenous device,(1,3,6,18) and always in the case of a patient with a complicated venous access.(1) Conclusion The contamination rate of blood cultures was 16.31%. The procedures used by nursing professionals are directly related to the contamination of the samples, since they do not always follow the procedure protocol. The study hypothesis is confirmed: the main factor influencing the contamination of samples is the workload of the emergency service, in which many prescriptions for blood cultures are requested, what possibly favors the use of little sterile technique. Acknowledgements Thanks to the Hospital Lluís Alcanyís for the kindness and cooperation at all times, both by the management team and the nurses team of the emergency unit. Collaborations De La Rubia-Ortí JE and Verdu-Trescolí G contributed to the project design, study execution, analysis and interpretation of data, writing, critical review of the relevant intellectual content and final approval of the version to be published. Prado-Gascó V and Firmino-Canhoto J collaborated in drafting the article, critical revision of the relevant intellectual content and final approval of the version to be published. Selvi-Sabater P contributed to the project design and execution of the research. References 1. Thompson F, Madeo M. Blood cultures: Towards zero false positives. J Infect. 2009;10(1 Suppl): s24-s26. 2. Julián-Jiménez A, Timón-Zapata J, EJ Laserna-Mendieta, CabezasMartínez Á. Usefulness of blood cultures in the emergency services. Rev Clin Esp. 2011;211(11):609-10. 3. Tudela P, Lacoma A, Prat C, Mòdol JM, Giménez M, Barallat J. Predicción de bacteriemia en los pacientes con sospecha de infección en urgencias. Med Clin. 2010;35(15):685-90. 4. Myers III FE, Reyes C. Hemocultivos: los 5 pasos correctos. Nursing. 2011;29(07):46-7. 5. Gonsalves WI, Cornish N, Moore M, Chen A, Varman M. Effects of volume and site of blood draw on blood culture results. J Clin Microbiol. 2009;47(11):3482-5. 6. Roth A, Wiklund A, Pålsson A, Melander E, Wullt M, Cronqvist J, et al. Reducing blood culture contamination by a simple informational intervention. J Clin Microbiol. 2010;48(12):4552-8. 7. García Allut M, Carnero Santas A, Romero García A, Aguilera Guirau A. Hemocultivo. Importancia en el medio hospitalario. ROL de Enfermería. 2011;173:27-30. 8. Kang H, Kim SC, Kim S. Comparison of chlorhexidine-alcohol and povidone-iodine for skin antisepsis and the effect of increased blood volume in blood culture. Korean J Clin Microbiol. 2012;15(1):37–42. 9. Madeo M, Barlow G. Reducing blood-culture contamination rates by Acta Paul Enferm. 2014; 27(2):144-50. 149 Contamination rate of blood tests and its determining factors 150 the use of a 2% chlorhexidine solution applicator in acute admission units. J Hosp Infect. 2008;69(3):307-9. 14. Moureau NL. ¿Ha actualizado las técnicas de preparación de la piel y de mantenimiento del catéter? Nursing (Ed. española). 2010;28(1):52-52. 10.Harding AD, Bollinger S. Reducing blood culture contamination rates in the emergency department. J Emerg Med. 2013;39(1):e16. 15.Caldeira D, David C, Sampaio C. Skin antiseptics in venous puncture-site disinfection for prevention of blood culture contamination: systematic review with meta-analysis. J Hosp Infect. 2011;77(3):223-32. 11.Sánchez Bermejo R, Rincón Fraile B, Cortés Fradique C, Fernández Centeno E, Peña Cueva S, de las Heras Castro EM. Hemocultivos…, Qué te han contado y qué haces? Enferm Glob. 2012;11(26):146-63. 16.Denno J, Gannon M. Practical steps to lower blood culture contamination rates in the emergency department. J Emerg Nurs. 2013;39(5):459-64. 12. Kim N, Kim M, Lee S, Yun NR, Kim K, Park SW, et al. Effect of routine sterile gloving on contamination rates in blood culture. A cluster randomized trial. Ann Intern Med. 2011;154(3):145-51. 17. Gander RM, Byrd L, DeCrescenzo M, Hirany S, Bowen M, Baughman J. Impact of blood cultures drawn by phlebotomy on contamination rates and health care costs in a hospital emergency department. J Clin Microbiol. 2009;47(4):1021-4. 13. Vives EA, Posse V, Oyarvide ML, Pérez Marc G, Medvedovsky D, Rothlin R. Antisépticos y Desinfectantes. Farmacología II. [Fecha creación: 26/03/2004]. [Fecha consulta Febrero 2013]. Disponible en: http:// www.ulceras.net. 18. Snyder SR, Favoretto AM, Baetz RA, Derzon JH, Madison BM, Mass D, et al. Effectiveness of practices to reduce blood culture contamination: A Laboratory Medicine Best Practices systematic review and metaanalysis. Clin Biochem. 2012;45(13):999-1011. Acta Paul Enferm. 2014; 27(2):144-50. Original Article Moral harassment experienced by nurses in their workplace Situações de assédio moral vivenciadas por enfermeiros no ambiente de trabalho Graziela Ribeiro Pontes Cahú1 Solange Fátima Geraldo da Costa1 Isabelle Cristinne Pinto Costa1 Patrícia Serpa de Souza Batista1 Jaqueline Brito Vidal Batista1 Keywords Social behavior; Ethics, nursing; Occupational health nursing; Working conditions; Occupational health Descritores Comportamento social; Ética em enfermagem; Enfermagem do trabalho; Condições de trabalho; Saúde do trabalhador Submitted February 7, 2014 Accepted March 26, 2014 Abstract Objectives: Investigate moral harassment experienced by nurses in their workplace. Methods: Cross-sectional study performed with 259 nurses working in primary healthcare units and public hospitals. The tool employed in the research was composed of a questionnaire available in the union council’s website, and the nurses were emailed the invitation to participate. Results: Results showed that the moral harassment phenomenon is more frequently regarded to the manipulation perpetrated by the aggressor toward opposed interests of the victim, followed by the acknowledgement that the harasser seeks to hinder the professional development of the harassed worker. Conclusion: The study revealed that the moral harassment experienced by the nurse in the workplace directly impacts his/her labor performance, as well as health and emotional statuses. Resumo Objetivos: Investigar situações de assédio moral vivenciadas por enfermeiros em seu ambiente de trabalho. Métodos: Pesquisa transversal realizada com 259 enfermeiros que trabalham em unidades básicas de saúde e hospitais da rede pública. O instrumento de pesquisa foi um questionário disponibilidade em um site do conselho de classe e os enfermeiros receberam por email o convite para participar. Resultados: Os resultados mostraram que a situação de assédio moral mais frequente diz respeito ao agressor manipular pessoas para assumir posicionamentos contrários aos interesses da vítima, seguida da constatação de que o assediador impede o crescimento profissional do assediado. Conclusão: O estudo revelou que situações de assédio moral vivenciadas pelo enfermeiro no ambiente de trabalho influenciam diretamente em o desempenho laboral, saúde e estado emocional. Corresponding author Graziela Ribeiro Pontes Cahú Cidade Universitária, João Pessoa, PB, Brasil. Zip Code: 58051-900 [email protected] DOI http://dx.doi.org/10.1590/19820194201400027 Universidade Federal da Paraíba, João Pessoa, PB, Brazil. Conflicts of interest: there are no conflicts of interest to declare. 1 Acta Paul Enferm. 2014; 27(2):151-6. 151 Moral harassment experienced by nurses in their workplace Introduction Moral harassment is deemed to be a subtle, dissimulated, intentional, repeated and prolonged psychological violence aimed at socially humiliating and excluding a given person in the work setting, resulting in psychosocial stress and several types of damage to both the society and the organization.(1) In order to characterize the harassment, the repercussion of the abusive conduct in the health status of the victim, the frequency and the duration of the abusive act, and the intentionality of the aggressors should be taken into account.(2) Abusive conducts stand out as those capable of damaging human dignity and may cause those who cannot stand them either to get ill or to make unexpected decisions regarding their professional lives, such as resign or change position/ department in the institution.(3) This is not a recent phenomenon in the work relations. Nevertheless, it has been reaching global dimensions lately, impacting different work contexts and professional segments.(3) Moral harassment has become an object of increasing concern worldwide to workers, employers and also the scientific community. The study of such phenomenon has been a growing trend in the healthcare area, above all in the psychology and medicine fields, due to the physical and psychic damages brought about by this type of violence. Researchers affirm that this violence in the work environment can be clearly observed in hospitals, where healthcare professionals are sometimes the perpetrators of the occupational abuse, and other times the victims of such violence, that is, aggressiveness and humiliation conditions are steadily reproduced and perpetuated in the work environment.(4) Among health team workers, this study identified that nurses are the major victims of moral harassment. For this reason, researchers show deep concern and alert that measures should be created in order to safeguard the physical and psychological integrity of health professionals, nurses in particular.(4) 152 Acta Paul Enferm. 2014; 27(2):151-6. It is worth highlighting that the nursing professional is a potential victim of moral harassment and that such practice may be perpetrated by the service manager, work colleagues, subordinated workers, other health team professionals, such as the doctor, for instance, as well as clients and patient’s family members.(5) Such information may lead to the conclusion that moral harassment in the nursing service is quite a frequent practice in the Brazilian scenario. Notwithstanding, there are no current data that can quantify such practice in the work of this professional segment. At the same time, the studies related to such issue in the daily work of nurses are quite incipient. The objective of the present study was to investigate moral harassment situations experienced by nurses in their workplace. Methods This exploratory research counts on a quantitative approach. All 259 nurses who participated in the study worked in primary healthcare units and public hospitals in the municipality of João Pessoa, Paraíba State. Inclusion criteria were as follows: nurses performing nursing activities at the moment of the data collection process; and nurses working in the nursing area for at least six months. It should be emphasized that the adopted sampling process was not probabilistic. The research instrument was built upon the variables of this study. Taking into account the confidential character of the study, the instrument was disclosed by electronic means at the official website of the Regional Nursing Council of Paraíba between June and August of 2011. The emails of the nurses invited to take part in the study were found in the referred Council’s database. After responding the questionnaire and pressing the Done key, the participant automatically received the confirmation of a document that could be visualized by the researcher in PDF, XLS, CSX and RTF extensions. With access to the document, the researcher responsible for the study was then Cahú GR, Costa SF, Costa IC, Batista PS, Batista JB able to manage the uploaded information. In order to be granted exclusive access to the information produced by the contents of the questionnaire, the researcher needed a login and password, so that the confidentiality of information could be preserved. Data were assessed by the Statistic Package for Social Sciences (SPSS) for Windows, version 19, and compared by frequencies and percentages. The development of the study complied with national and international ethical guidelines for research involving human beings. Results Harassers are capable of promoting repeated attacks, such as initial subtle attitudes that are intensified as time passes. In order to assault the victim, the harasser humiliates, chastises, constrains, and isolates, among other embarrassing situations, causing the worker to undergo physical and mental suffering. Moral harassment shows distinct characteristics in various conditions. Therefore, aiming to more profoundly understand the moral harassment experienced by the nurses who participated in the study, the tables below display the conducts carried out by the aggressor, according to the information provided by the participants. It should be highlighted that the quoted conducts were grouped and correlated in four categories, namely: purposeful deterioration of work conditions; attack against dignity; isolation and refusal to communication; and verbal, physical and sexual abuse. Table 1 highlights the responses of the participants in the study concerning aggressive situations undergone in the work environment in the category of purposeful deterioration of work conditions. This category shows that the most recurrent type of violence is related to “manipulation that leads people to stand against the victim’s interests”, followed by the observation that such behavior “hinders professional development”. The attack against dignity category showed that the main responses of the participants in the study were: unfairly and exaggeratedly criticizes your work (47.41%); spreads bad words and slanders about you (40.52%); publicly speaks negative things about you (31.03%); and insinuates and spreads rumors that you have a health problem (6.03%). Table 1. Aggression situations undergone in the workplace in the category of purposeful deterioration of work conditions Purpose deterioration of work conditions % Manipulates people toward taking up positions that go against their interests 47.41 Hinders professional development 40.52 Systematically confronts all decisions 27.59 Restrains rights only to generate damage (vacations, rewards, time schedules) 31.90 Delegates excessive amounts of activities 22.41 Provides confusing and inaccurate information 22.41 Does not convey other useful information toward the performance of tasks 22,41 Requires urgent, yet totally unnecessary tasks 22.41 Forces you to resign 22.41 Obstructs work progress 21.55 Does not take health problems into account 19.83 Provides instructions that are impossible to be executed 18.97 Removes the work that usually belongs to you 18.97 Deprives you from work instruments: telephone, fax, computer, table, among others 17.24 Orders you to perform uninteresting tasks 16.38 Sends registered warning letters 16.38 Induces you to errors 13.79 Assigns tasks that are not compatible with your health status 12.07 Purposefully and systematically assigns tasks that are lower than your competences 11.21 Purposefully and systematically assigns tasks that are higher than your competences 10.34 Imposes unjustifiable time schedules 10.34 Does not provide any service at all 2.59 Source: Empirical material of the research, João Pessoa, Paraíba, Brazil. 2011 Table 2 shows aggression situations undergone in the workplace in the verbal, physical and sexual abuse category. Verbal abuse was on the top of the list in the assessed sample, reaching 32.76%. Acta Paul Enferm. 2014; 27(2):151-6. 153 Moral harassment experienced by nurses in their workplace Table 2. Aggression situations undergone at the workplace in the category of verbal, physical and sexual abuse Verbal, physical and sexual abuse % Yells at you 32.76 Attacks you only when nobody else is around 12.57 Meddles in your private life with phone calls, e-mails, letters 5.17 Physically attacks you, although in a mild way, pulls you out and slams the door on your face 4.32 Threatens to physically attack you 2.59 Sexually harasses or attacks you (gestures or proposals) 1.72 Injures your car 0.86 Source: Empirical material of the research, João Pessoa, Paraíba, Brazil. 2011 Table 3 shows aggression situations in the workplace occurred between the harasser and the victim concerning isolation and refusal to communication. This category shows that the most frequent response is related to the aggressions ignores you in the presence of other people, followed by interrupts you when you start talking. Table 3. Isolation and refusal to communication Isolation and refusal to communication % Ignores you in the presence of other people 55.17 Interrupts you when you start talking 37.07 Threatens to transfer you to another department, in order to isolate you 13.79 Does not talk to you anymore 12.07 Segregates you from the others 11. 21 Transfers you to another department, in order to isolate you 10.34 Uses written communication with you only 9.48 Prohibits your colleagues to talk to you 8.62 Source: Empirical material of the research, João Pessoa, Paraíba, Brazil. 2011 Discussion The attitudes related to the purposeful deterioration of work conditions are harder to be spotted. The present study observed that the most frequent aggression situations are regarded to the manipulation of people by the harasser so that they take positions that are opposite to the interests of the victim, followed by the observation that the harasser hinders the harassed worker’s professional development. 154 Acta Paul Enferm. 2014; 27(2):151-6. A study points out that the harasser might defend himself/herself justifying that he/she acted that way in order to improve the service activities.(6) It is worth highlighting that the purpose of the harasser is to cause people to realize that the victim is incompetent.(7) In these cases, subtle proceedings are carried out, such as: to systematically confront all the victim’s decisions, not to take health problems into account, to remove activities that used to be usually assigned to the subject, to provide instructions that are impossible to be executed, to induce the victim to error, and not to allow the worker to have access to useful information in the execution of tasks. The aggressor manipulates the victim’s work by making use of mechanisms such as: delegation of excessive activities, assignment of unnecessary urgent tasks, purposeful and systematic assignment of tasks that are lower or higher than the victim’s competence, lack of assignment of any task, and deprivation of the victim’s access to the necessary work instruments in his/her professional activity, among others.(8) Other forms of expression of the moral harassment aimed to deteriorate the work conditions of the victim are related to labor rights and compensatory labor measures. Here, the authors identify attitudes, such as restriction to the right to vacation, imposition of unjustifiable work schedules, wage discrimination, as well as arbitrary changes of work schedules.(8) As the victim starts being discredited by colleagues, managers and other workers, the harasser manipulates people and cause them to take positions that are opposite to the interests of the victim, thus hindering his/her professional development and even sending him/her written warnings under the justification that the professional lacks competence and is not up to the demands of the service. The victim usually ends up feeling abandoned, disheartened and put under intense psychic suffering, not rarely giving up the job. As for the aggression situations undergone in the workplace in the category of attack against dignity, it was observed that the harasser criticizes the work of the victim in an unfair, exaggerated way (47.41%), spreading bad words and slanders about Cahú GR, Costa SF, Costa IC, Batista PS, Batista JB him/her (40.52%), and publicly speaking negative things about him/her (31.03%). The attack against dignity is described as a behavior that is easily perceived by everybody; nevertheless, people believe that the victim is the one to blame.(7) Attitudes related to this category are aimed to disqualify the victim. In general, harassers and work colleagues disqualify and criticize the work of the victim in an exaggerated, unjustifiable way, making derogatory remarks and exposing him/her to public mockery. Expressions such as he/she is very sensitive, or he/she is paranoid, are frequently used to stigmatize the victim. In these situations, the aggressor manipulates the reputation of the victim, as the criticism is often related to damaging comments on the person’s professionalism and even physical aspects or religious beliefs. Verbal, physical and sexual abuse is also perceived in the moral harassment. The study shows that, in this category, moral harassment is presented in an explicit way, as threats and physical aggressions, regardless their intensity, may occur.(7) Embarrassing, humiliating situations, such as yells, invasion of privacy of the victim by means of phone calls, emails, letters, among others, are clearly shown in this category. Regarding the aggression situations undergone in the workplace, the category of verbal, physical and sexual abuse was put on top of the list by the participants in the study, 32.76%. The situation in which the harasser attacks the victim only when there is nobody else in the place was also indicated several times by the participants in the study (12.57%). Such data also reveal that moral harassment can be invisible. The sample shows that it is very difficult for the victim to prove an eventual harassment process when the aggressor does not leave any fingerprint behind, quite a frequent occurrence, as these aggressions take place when nobody else, but the harasser and the victim, witness the conflict. A harassment process is defined by the repetition of that act. It is important to highlight that moral harassment is a process in which the worker undergoes a psychic massacre. Moral harassment, in other words, stands out as a series of interdepen- dent acts aimed to achieve a final destructive goal. (9) Hence, habitual tensions, as well as isolated conflicts and incidents, so pertinent in modern organizations, must be discarded.(8) Similarly, harassed employees repeatedly complained about being shoved out, even mildly, as part of the physical violence present in moral harassment. As for sexual harassment, it is worth emphasizing that its similarities with moral harassment are the repetition of abusive actions, relentless persecution and power abuse. Nevertheless, a study(10) affirms that they are distinct phenomena, despite the close connections between one another. Sexual harassment may constitute the premise that unleashes moral harassment, a result of the vengeance of the rejected aggressor against the victim. It is important to state that sexual harassment is characterized by the sexual conduct rejected by the victim. The purpose of the harasser is to achieve sexual advantages. In the moral harassment, on the other hand, the aggressor’s intention is to deteriorate the work environment, so that the victim quits the job.(9) As for the aggressions occurred between harasser and victim regarding the category of isolation and refusal to communication, it was observed that the most frequently recorded situation is when the harasser public ignores the presence of the victim (55.17%). In this case, the harasser despises the victim so that others realize that he/she is no longer needed in the company. Such conduct is evidenced by means of mechanisms used by the aggressor to establish an implicitly hostile communication with the victim, revealing that the final objective of this action is to manipulate the victim’s communication. Such interruption and refusal to communication end up psychologically destabilizing the harassed person. By ignoring him/her, the harasser isolates and excludes him/her, and also disqualifies him/her in a subtle, subjective manner.(11) Isolation is quite a clear characteristic of moral harassment. It stands out as a set of actions aimed to hinder the harassed person to communicate and establish social contacts within the work setting, thus strongly damaging his/her socio-professional interactions. In this sense, attitudes such as to ignore the victim’s presence publicly, interrupt his/her Acta Paul Enferm. 2014; 27(2):151-6. 155 Moral harassment experienced by nurses in their workplace conversation, threaten to transfer him/her, isolate him/her, avoid speaking with him/her, communicate only by written form, segregate him/her from the others, and prohibit colleagues of speaking to him/her were all recorded in this phase of the studied phenomenon. Results indicate how relevant it is to inform nursing professionals on the existence and the steady occurrence of the moral harassment, as well as the potential consequences the victims may undergo as a result of this type of psychological suffering. They also show the importance of the implementation of preventive actions, taking into account the significance of a healthy, friendly environment for the health of the workers. Conclusion Nurses reported several situations of moral harassment in the workplace that directly influenced their work performance, their health and their emotional status. Collaborations Cahú GRP collaborated with the conception of the project, execution of the research and drafting of the article. Costa SFG contributed to the conception of the project, execution of the research, drafting of the article, and approval of the final version of the article to be published. Costa ICP; Batista PSS and Batista JBV collaborated with the relevant critical review of the intellectual content. 156 Acta Paul Enferm. 2014; 27(2):151-6. References 1. Cahú GR, Rosenstock KI, Costa SF, Leite AI, Costa IC, Claudino HG. [Scientific production in journals online on the practice of bullying: an integrative review]. Rev Gaúcha Enferm. 2011;32(3):611-9. Portuguese. 2. Azevedo AL, Araújo ST. [The visibility of moral harassment in the work of nursing]. Rev Pesp Cuid Fundam. 2012; 4(3):2578-84. Portuguese. 3. Battistelli BM, Amazarray MR, Koller SH. [Mobbing at work according to operators of the law]. Psicol Soc. 2011;23(1):35-45. Portuguese. 4. Cezar ES, Marziale MH. [Occupational violence problems in an emergency hospital in Londrina, Paraná, Brazil]. Cad Saúde Pública. 2006; 22(1):217-21. Portuguese. 5. Dias HH, Ramos FR.[The care (lessness) in the nursing work with chemical dependents].Texto & Contexto Enferm. 2003;12(1):44-51. Portuguese. 6. Nunes TS, Tolfo SR. Assédio moral no trabalho: consequências identificadas por servidores docentes e técnico-administrativos em uma Universidade Federal Brasileira. Revista GUAL. 2012;5(3):26486. Portuguese. 7. Garbin AC, Fischer FM. Assédio moral no trabalho e suas representações na mídia jornalística. Rev Saúde Pública. 2012; 6(3): 417-24. Portuguese. 8. Guimarães LA, Rimoli AO. [Workplacemobbing: a multidimensional psychosocialsyndrome]. Psicol Teor Pesq. 2013;22(2):183-91. Portuguese. 9. Fontes KB, Carvalho MD. [Variables involved in the perception of psychological harassment in the nursing work environment]. Rev Latinoam Enferm. 2012; 20(4):761-8. Portuguese. 10.Guedes MN. Assédio Moral e responsabilidade das organizações com os direitos fundamentais dos trabalhadores. Rev Amantra II.2003; 4(10). Available from: http://biblioteca.planejamento.gov.br/ biblioteca-tematica-1/textos/trabalho-e-previdencia/texto-9-2013assedio-moral-no-ambiente-de-trabalho-e-a-responsabilidade-civilempregado-e-empregador.pdf. Portuguese. 11. Ferreira JB, Mendes AM, Calgaro JC, Blanch, JM. [Moral harassment of amnestied professionals at a public organization]. Psicol Rev. 2006; 12(20):215-33. Portuguese Original Article Quality of life before and after bariatric surgery Qualidade de vida antes e após a cirurgia bariátrica Josiane da Motta Moraes1 Rita Catalina Aquino Caregnato1,2 Daniela da Silva Schneider1 Keywords Quality of life/psychology; Bariatric surgery; Obesity, morbid/surgery; Obesity, morbid/psychology; Questionnaires Descritores Qualidade de vida/psicologia; Cirurgia bariátrica; Obesidade mórbida/ cirurgia; Obesidade mórbida/psicologia; Questionários Submitted February 4, 2014 Accepted April 14, 2014 Corresponding author Daniela da Silva Schneider Sarmento Leite street, 245, Porto Alegre, RS, Brazil. Zip Code: 90050-170 [email protected] DOI http://dx.doi.org/10.1590/19820194201400028 Abstract Objective: Knowing the quality of life of obese patients before and after bariatric surgery. Methods: A cross-sectional and prospective study that included 16 obese patients who underwent bariatric surgery. The survey instrument was the Whoqol-bref translated and validated for the Portuguese language. Data were collected before and after the bariatric surgery. The SPSS 19.0 was used for data analysis with application of the McNemar’s test for related samples, considering p<0.05 significant. Results: Before surgery 25% of participants considered their quality of life and health as bad or very bad, showing dissatisfaction. After surgery, all assessed their quality of life and satisfaction with health as good or very good. The percentages found in relation to negative feelings were better; it was observed that 62.5% did not express negative feelings anymore or only sometimes had these feelings. Conclusion: The results showed that the quality of life, health, feelings, satisfaction and ability to do things has improved after bariatric surgery. Resumo Objetivo: Conhecer a qualidade de vida antes e após a cirurgia bariátrica. Métodos: Estudo transversal e prospectivo que incluiu 16 obesos que se submeteram à cirurgia bariátrica. O instrumento de pesquisa foi o Whoqol-bref traduzido e validado para língua portuguesa. Os dados foram coletados antes e após a cirurgia bariátrica. Para a análise dos dados utilizou-se o Software SPSS 19.0 com aplicação do teste Mc Nemar para amostras relacionadas, considerando-se como significativo p<0,05. Resultados: Antes da cirurgia, 25% consideraram a qualidade de vida e saúde ruim ou muito ruim, mostrandose insatisfeitos. Depois da cirurgia, todos avaliaram a qualidade de vida e satisfação com a saúde como boa ou muito boa. Os percentuais encontrados em relação aos sentimentos negativos melhoraram; observou-se que 62,5% manifestaram não ter mais, ou apenas sentir algumas vezes, sentimentos negativos. Conclusão: Os resultados mostraram que a qualidade de vida, saúde, sentimentos, satisfação e capacidade de realizar coisas melhoraram após a cirurgia bariátrica. Universidade Luterana do Brasil, Canoas, RS, Brazil. Universidade Federal de Ciências da Saúde, Porto Alegre, RS, Brazil. Conflicts of interest: no conflicts of interest to declare. 1 2 Acta Paul Enferm. 2014; 27(2):157-64. 157 Quality of life before and after bariatric surgery Introduction Considered a global epidemic, obesity is a chronic disease of metabolic and/or genetic origin related to excess body fat, which can trigger conditions such as diabetes; cardiovascular diseases such as hypertension, myocardial infarction, thrombosis, embolism and arteriosclerosis; orthopedic problems; asthma; sleep apnea; some cancers; hepatic steatosis and psychological disorders.(1-3) Therefore, the increase in body weight is associated with many comorbidities.(4) Overweight and obesity have increased in the last six years in Brazil. The proportion of overweight people increased from 42.7% in 2006 to 48.5% in 2011; the percentage of obese also rose from 11.4% to 15.8%.(4) This growth tends to decline over the next ten years. This scenario has set a great impact on public health and costs associated with obesity treatments.(5) The Body Mass Index is determined by dividing the individual’s weight (in kilograms) by the square of the height (in meters). Underweight is defined when this value is less than 18.5; ideal weight is any value between 18.5 and 24.90; overweight is between 25 and 29.90; obesity is between 30 and 34.9; severe obesity between 35 and 39.9; and morbid obesity is any value greater than 40.(6) There is evidence that moderate weight loss (510% of initial weight) with conventional treatment by nutritional and pharmacological approaches plus physical activity, promotes metabolic benefits. However, for the treatment and management of morbid obesity, the most effective tool is surgical intervention.(1,2,7) The surgical procedure results in significant and lasting weight loss, preventing complications that threaten the quality of life, improving comorbidities and increasing longevity. Quality of life is a multidimensional and subjective construct, which complicates its definition. The perception of individuals of their position in sociocultural context, including their goals, expectations, standards and concerns is an important aspect in the evaluation. It is closely related to personal wellbeing and covers aspects such as the health condition, leisure, personal satisfaction, and lifestyle habits.(8) 158 Acta Paul Enferm. 2014; 27(2):157-64. Hence, bariatric surgery can improve quality of life because it facilitates the body locomotion, decreases psychosocial and self-esteem damages, avoiding chronic and metabolic diseases.(3,9) The preparation of patients for bariatric surgery requires adequate involvement of a multidisciplinary team, both in the pre-operative and post-operative periods, conducting the diagnostic evaluation and appropriate treatment, individual, marital or family therapy, with specific guidelines about the surgery, in order to discuss and adjust the patient’s expectations to the limitations of surgical treatment.(10) Patients undergoing bariatric surgery should be prepared for nutritional education, reducing the amount of food ingested for lasting weight loss, and be aware of possible complications resulting from surgery.(7,11) The reduction of the stomach can present major risks to compulsive patients, leading to psychological disorders.(9) This study aimed at knowing the quality of life of obese patients before and after bariatric surgery. Methods This is a prospective cross-sectional study on the quality of life of patients in the pre and postoperative periods of bariatric surgery. The research site was the clinic of a private hospital located in a municipality in the countryside of the state of Rio Grande do Sul, southern Brazil. The clinic, called “Espaço Vida” offers laboratory tests, ultrasound and bone densitometry, nursing care services, and has an amphitheater and a meeting room, where guidance and advising are done before and after bariatric surgery. The sample was intentional of 16 morbidly obese patients who would be undergoing bariatric surgery with mixed surgical technique, which allows more restrictive component, comprising the various forms of gastric bypass with Roux-en-Y restoration of intestinal transit. Inclusion criteria were adults over 18 years, with indication of bariatric surgery and who attended multidisciplinary meetings to prepare for bariatric surgery. Moraes JM, Caregnato RC, Schneider DS The survey instrument was the World Health Organization Quality of Life (Whoqol-bref ) translated and validated for the Portuguese language, which covers the complexity of the construct and interrelates the environment with physical and psychological aspects, level of independence, social relationships and personal beliefs.(11) The instrument consists of 26 questions, the first concerning the quality of life in general, and the second concerns the satisfaction with one’s own health. The other 24 are divided into physical and psychological domains, and also domains of social relationships and environment relations. This instrument can be used for both healthy populations and for populations with chronic diseases and injuries. Besides the transcultural character, it values the individual perception and assesses the quality of life in many groups and situations.(11) The data collection was carried out at the completion of multidisciplinary meetings to prepare for surgery and three months after surgery. The frequency analysis was done, as well as the results of continuous variables as mean ± standard deviation. The McNemar’s test was used for related samples noting the significance of changes applicable to experiments of the ‘before and after’ type. In order to verify the normality of data was used the Kolmogorov-Smirnov test, and values of p < 0.05 were considered significant. Data analysis was done with the SPSS 19.0. The development of the study followed the national and international standards of ethics in research involving human beings. Results The time to complete the questionnaire was of 11 minutes before the surgery and seven minutes after the surgery; only one patient asked for help from a family member to complete the questionnaire in the preoperative period. The study population consisted of women (93.75%), married (75%), four health professionals (25%) - a nutritionist and three nursing technicians. The others were three self-employed profes- sionals, six people with complete high school and two students. Table 1 shows the results of quality of life, health, feelings and satisfaction of the morbidly obese expressed by respondents before and after bariatric surgery through frequency analysis. It was found that, prior to surgery 25% considered their quality of life and health as bad or very bad, showing dissatisfaction. After surgery, all of them assessed the quality of life and satisfaction with their health as good or very good. The percentages found in relation to negative feelings were better; it was observed that after the surgery 62.5% did not express negative feelings anymore or only sometimes had these feelings such as, bad mood, despair, anxiety and depression. It was observed that the majority showed an intermediate position when answering about the feelings they had in the two previous weeks; after surgery the majority (81.25%) reported no pain or very little pain when doing physical activities, 93.75% expressed to be enjoying life more. It is noteworthy that 100% expressed having found meaning in life after the surgery. Also, in the items of safety, concentration and health in the physical environment, they answered to be quite pleased. Regarding satisfaction expressed in the last two weeks of the pre-operative period, it was identified that the majority (68.75%) did not physically accept themselves and that 68.75% had no opportunity to do leisure activities. The only variable that did not change postoperatively was having enough money. Table 2 shows the frequency analysis of the opinion of morbidly obese patients in relation to their ability to perform. Before surgery, 50% responded feeling difficulty in performing everyday life activities. It was observed that the most participants (68.75%) found themselves satisfied with social relationships; 75% said they were satisfied or very satisfied with the support and the place of residence, and 81.25% reported to have access to services. Regarding the ability to do things, it became evident in the postoperative period that the majority was satisfied. Acta Paul Enferm. 2014; 27(2):157-64. 159 Quality of life before and after bariatric surgery Table 1. Quality of life, health, feelings and satisfaction before and after bariatric surgery Evaluation Before Assessment of quality of life Satisfaction with health Frequency of negative feelings such as bad mood, despair, anxiety, depression After Assessment of quality of life Satisfaction with health Frequency of negative feelings such as bad mood, despair, anxiety, depression Bad n(%) Neither bad nor good n(%) Good n(%) Very good n(%) 1(6.25) 3(18.75) 6(37.5) 6(37.5) 0(0) Very dissatisfied n(%) Dissatisfied n(%) Neither satisfied nor dissatisfied n(%) Satisfied n(%) Very satisfied n(%) 1(6.25) 3(18.75) 6(37.5) 6(37.5) 0(0) Never n(%) Sometimes n(%) Frequently n(%) Very frequently n(%) Always n(%) 0(0) 6(37.5) 3(18.75) 6(37.5) 1(6.25) Very bad n(%) Bad n(%) Neither bad nor good n(%) Good n(%) Very good n(%) 0(0) 0(0) 0(0) 5(31.25) 11(68.75) Very dissatisfied n(%) Dissatisfied n(%) Neither satisfied nor dissatisfied n(%) Satisfied n(%) Very satisfied n(%) 0(0) 0(0) 0(0) 7(43.75) 9(56.25) Never n(%) Sometimes n(%) Frequently n(%) Very frequently n(%) Always n(%) 4(25) 6(37.5) 1(6.25) 4(25) 1(6.25) None n(%) Very little n(%) More or less n(%) Very much n(%) Extremely n(%) Impediment of activities because of physical pain 0(0) 1(6.25) 7(43.75) 7(43.75) 1(6.25) Need for medical treatment to lead the daily life 2(12.5) 3(18.75) 6(37.5) 4(25) 1(6.25) 0(0) 4(25) 8(50) 4(25) 0(0) Meaning of life 2(12.5) 0(0) 6(37.5) 5(31.25) 3(18.75) Amount of concentration 1(6.25) 2(12.5) 8(50) 4(25) 1(6.25) Security in life 1(6.25) 2(12.5) 9(56.25) 3(18.75) 1(6.25) 0(0) 2(12.5) 10(62.5) 3(18.75) 1(6.25) None n(%) Very little n(%) More or less n(%) Very much n(%) Extremely n(%) Impediment of activities because of physical pain 5(31.25) 8(50) 2(12.5) 1(6.25) 0(0) Need for medical treatment to lead the daily life 4(25) 6(37.50) 5(31.25) 1(6.25) 0(0) Enjoyment of life 0(0) 0(0) 1 (6,25) 13(81.25) 2(12.5) Meaning of life 0(0) 0(0) 0 (0) 8 (50) 8(50) Amount of concentration 0(0) 0(0) 4(25) 11(68.75) 1(6.25) Security in life 0(0) 0(0) 2(12.5) 11(68.75) 3(18.75) Health of physical environment (climate, noise, pollution, leisure) 0(0) 3(18.75) 3(18.75) 8(50) 2(12.50) Nothing n(%) Very little n(%) Average n(%) Very much n(%) Completely n(%) Before Enjoyment of life Health of physical environment (climate, noise, pollution, leisure) After Before Enough energy for daily living 1(6.25) 4(25) 10(62.5) 1(6.25) 0(0) Acceptance of physical appearance 5(31.25) 6(37.5) 2(12.5) 3(18.75) 0(0) Enough money to meet the needs 0(0) 4(25) 11(68.75) 1(6.25) 0(0) Availability of information needed in day by day 0(0) 2(12.5) 5(31.25) 6(37.5) 3(18.75) Opportunity to do leisure activity 0(0) 11(68.75) 5(31.25) 0(0) 0(0) Nothing n(%) Very little n(%) Average n(%) Very much n(%) Completely n(%) Enough energy for daily living 0(0) 0(0) 5(31.25) 7(43.75) 4(25) Acceptance of physical appearance 0(0) 0(0) 1(6.25) 4(25) 11(68.75) Enough money to meet the needs 0(0) 2(12.5) 10(62.5) 2(12.5) 2(12.5) After Availability of information needed in day by day Opportunity to do leisure activity 160 Very bad n(%) Acta Paul Enferm. 2014; 27(2):157-64. 1(6.25) 0(0) 2(12.5) 10(62.5) 3(18.75) 0(0) 2(12.5) 5(31.25) 7(43.75) 2(12.5) Moraes JM, Caregnato RC, Schneider DS Table 2. Ability to perform Very bad n(%) Bad n(%) Neither bad nor good n(%) Good n(%) Very good n(%) 0(0) 7(43.75) 3(18.75) 6(37.5) 0(0) 1(6.25) 1(6.25) 10(62.5) 4(25) 0(0) Satisfaction with the ability to perform day-to-day activities 0(0) 8(50) 5(31.25) 2(12.5) 1(6.25) Satisfaction with the ability to perform work. 0(0) 7(43.75) 4(25) 3(18.75) 2(12.5) 2(12.5) 5(31.25) 7(43.75) 1(6.25) 1(6.25) 0(0) 1(6.25) 4(25) 6(37.5) 5(31.25) 3(18.75) 1(6.25) 7(43.75) 3(18.75) 2(12.5) 0(0) 1(6.25) 3(18.75) 5(31.25) 7(43.75) 1(6.25) 1(6.25) 2(12.5) 5(31.25) 7(43.75) Satisfaction with access to health services 0(0) 1(6.25) 2(12.5) 8 (50) 5(31.25) Satisfaction with means of transportation 0(0) 1(6.25) 4(25) 8 (50) 3(18.75) Mobility 0(0) 0(0) 0(0) 5(31.25) 11(68.75) Satisfaction in relation to sleep 0(0) 0(0) 3(18.75) 6(37.5) 7(43.75) Satisfaction with the ability to perform day-to-day activities 0(0) 1(6.25) 0(0) 6(37.5) 9(56.25) Satisfaction with the ability to perform work 0(0) 0(0) 1(6.25) 5(31.25) 10(62.50) Self-satisfaction 0(0) 0(0) 4(25) 3(18.75) 9(56.25) Satisfaction with personal relationships (friends, relatives, acquaintances, colleagues) 0(0) 0(0) 2(12.5) 7(43.75) 7(43.75) Satisfaction with sex life 0(0) 1(6.25) 2(12.5) 7(43.75) 6(37.5) Satisfaction with the support received from friends 0(0) 0(0) 0(0) 7(43.75) 9(56.25) 1(6.25) 0(0) 1(6.25) 7(43.75) 7(43.75) Satisfaction with access to health services 0(0) 0(0) 0(0) 11(68.75) 5(31.25) Satisfaction with means of transportation 0(0) 0(0) 0(0) 8(50) 8(50) Variables Before surgery Mobility Satisfaction in relation to sleep Self-satisfaction Satisfaction with personal relationships (friends, relatives, acquaintances, colleagues) Satisfaction with sex life Satisfaction with the support received from friends Satisfaction with the conditions of the place of residence After surgery Satisfaction with the conditions of the place of residence The comparison between the level of satisfaction before and after surgery is shown in table 3. In order to investigate the association between the level of satisfaction before and after surgery was used the McNemar’s test, indicated for related samples and considered significant with p-value < 0.05. Table 1 shows many variables with statistically significant association in relation to patient satisfaction when comparing the opinions expressed in the preoperative and postoperative periods. The percentage of patients’ satisfaction before surgery was 63.22%, and after surgery it was 81.01% (p = 0.001). 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, all 16 bariatric surgeries performed at the study site were included in the analysis (100%). Bariatric surgery brings many changes in the lives of obese, hence monitoring is important for adaptation and adherence to treatment. The results showed that respondents judged to have improved their quality of life and health after surgery. Studies have shown that after bariatric surActa Paul Enferm. 2014; 27(2):157-64. 161 Quality of life before and after bariatric surgery Table 3. Evaluation of patient satisfaction before and after bariatric surgery Percentage of satisfaction in surgery Variables p-value Before % After % Assessment of quality of life 37.50 100.00 0.01 Satisfaction with health 37.50 100.00 0.01 Impediment of activities because of physical pain 50.00 81.25 0.02 Need for medical treatment to lead the daily life 31.25 62.50 0.08 Enjoyment of life 25.00 93.75 0.01 Meaning of life 50.00 100.00 0.01 Amount of concentration 31.25 75.00 0.21 Security in life 25.00 87.50 0.01 Health of physical environment (climate, noise, pollution, leisure) 25.00 62.50 0.03 Quality of life and health Feelings in the two previous weeks Satisfaction in the two previous weeks Enough energy for daily living 6.25 68.75 0.04 Acceptance of physical appearance 18.75 93.75 0.03 Enough money to meet the needs 6.25 25.00 0.08 Availability of information needed in day by day 56.25 81.25 0.27 Ability to do things 37.50 100.00 0.03 Satisfaction in relation to sleep. 25.00 81.25 0.01 Satisfaction with the ability to perform day-to-day activities 18.75 93.75 0.02 Satisfaction with the ability to perform work. 31.25 93.75 0.18 Self-satisfaction 12.50 75.00 0.02 Satisfaction with sex life 31.25 81.25 0.01 Satisfaction with the support received from friends 75.00 100.00 0.08 Satisfaction with the conditions of the place of residence 75.00 87.50 0.58 Satisfaction with access to health services 81.25 99.25 0.16 Satisfaction with means of transportation 68.75 100.00 0.04 43.75 31.25 0.10 Mobility Satisfaction with personal relationships (friends, relatives, acquaintances, colleagues) Negative feelings Frequency of negative feelings such as bad mood, despair, anxiety, depression gery there is a gradual decrease of body mass index, metabolic improvement, reduction of hypertension and type II diabetes mellitus.(7,12,13) These results can contribute to the planning of nursing care before and after bariatric surgery, for health education and for coping with any complications. Musculoskelatal pain in lower limbs decreased, and episodes of chronic pain also decreased after surgery. Several studies showed the same results.(14-18) Regarding the variables related to satisfaction throughout the last two weeks, there was no difference before and after surgery only in the money aspect. For all the other variables - 162 Acta Paul Enferm. 2014; 27(2):157-64. enough energy for the day, acceptance of physical appearance, availability of information and opportunity to do leisure activity - the result was satisfaction after surgery, highlighting that the majority showed acceptance in relation to their own physical appearance. It was observed in this study, that after surgery all participants were satisfied with the ability to do things related to basic needs such as sleep, locomotion, sexual activity, interpersonal relationships and others. A study that used the International Index Erectile Function (IIEF) questionnaire for the investigation, concluded Moraes JM, Caregnato RC, Schneider DS that two years after bariatric surgery, with reduced caloric intake and decreased body mass index, there was considerable improvement in the quality of sexual life.(1) A study on the mobility of locomotion showed that the distance traveled by the obese was longer and with less pain after bariatric surgery.(15) This finding is in agreement with the results of this research, in which mobility was better after surgery. Another research has shown that obese people were not happy with their bodies, did not enjoy going out and received unkind nicknames. (19) In this research, in the preoperative period, participants did not show satisfied nor dissatisfied with themselves; however, in relation to interpersonal relationships with colleagues, the majority reported feeling well. A study on binge eating before and after bariatric surgery considered that the characteristics of compulsion, impaired emotional structure, anxiety, depression and difficulty in elaborating emotions should be considered risk factors for postoperative complications.(10) A review study indicated improvement in clinical and functional conditions after bariatric surgery, but there was high prevalence of mental disorders in the population of bariatric patients, some with changes related to eating behavior, depressive syndromes, abuse of alcohol and other substances, anxiety and complications associated with impulsive behavior.(20) The results showed that after bariatric surgery, 15 (60%) out of the 25 studied variables were significant. Collaborations Moraes JM; Caregnato RCA and Schneider DS participated in the project design, analysis and interpretation of data, critical review of the relevant intellectual content and final approval of the version to be published. Conclusion 11.Kluthcovsky AC, Kluthcovsky FA. O WHOQOL-bref, um instrumento para avaliar qualidade de vida: uma revisão sistemática. Rev Psiquiatr Rio Grande do Sul. 2009; 31(3 Supl.). The results showed that the quality of life, health, feelings, satisfaction and ability to do things has improved after bariatric surgery. Acknowledgements We thank the institutional support received for the study, and Professor Dr. Karin Viegas for her collaboration. References 1. Araújo AA, Brito AM, Ferreira MN, Petribú K, Mariano MH. Modificações da qualidade de vida sexual de obesos submetidos à cirurgia de FobiCapella. Rev Col Bras Cir. 2009; 36(1):42-8. 2. Magdaleno-Júnior R, Chaim EA, Turato ER. Características psicológicas de pacientes submetidos à cirurgia bariátrica. Rev Psiquiatr Rio Grande do Sul. 2009;31(1):73-8. 3. Melo ME, Mancini MC. Obesidade como diagnosticar e tratar. Revista Brasileira de Medicina. São Paulo: Moreira Jr; 2009. 4. Brasil. Ministério da Saúde. Quase metade da população brasileira está acima do peso. Portal Saúde, 10 Abr. 2012 [citado 2013 Ago 18]. Disponível em: <http://portalsaude.saude.gov.br/portalsaude/ noticia/4718/162/quase-metade-da-populacao-brasileira-estaacima-do-peso.htm. 5. Mendes P. SUS gasta R$ 488 mil em um ano com doenças ligadas à obesidade. Portal G1, 19 Mar. 2013 [citado 2013 Out 20]. Disponível em: <http://g1.globo.com/bemestar/noticia/2013/03/sus-gasta-r488-milhoes-por-ano-com-doencas-ligadas-obesidade.html. 6. Associação Brasileira para o Estudo da Obesidade e da Síndrome Metabólica. Diretrizes brasileiras de obesidade 2009/2010. 3a ed. Itapevi: AC Farmacêutica; 2009. 7. Pedrosa IV, Burgos MG, Souza NC. Morais CN. Aspectos nutricionais em obesos antes e após a cirurgia bariátrica. Rev Col Bras Cir. 2009;36(4):316-22. 8. Pucci GC, Rech CR, Fermino RC, Reis RS. Associação entre atividade física e qualidade de vida em adultos. Rev Saúde Pública. 2012; 46(1):166-79. 9. Leal CW, Baldin N. O impacto emocional da cirurgia bariátrica em pacientes com obesidade mórbida. Rev Psiquiatr Rio Grande do Sul. 2007; 29(3): 324-7. 10.Machado CE, Zilberstein B, Cecconello I, Monteiro M. Compulsão alimentar antes e após a cirurgia bariátrica. ABCD Arq Bras Cir Digestiva. 2008;21(4):185-91. 12.Carvalho MV, Siqueira LB, Sousa ALL, Jardim PC. A influência da hipertensão arterial na qualidade de vida. Arq Bras Cardiol. 2013;100(2):164-74. 13. Forcina DV, Almeida BO, Ribeiro-Júnior MA. Papel da cirurgia bariátrica no controle do Diabete Melito Tipo II. ABCD Arq Bras Cir Digestiva. 2008;21(3):130-2. 14. Melo IT, São-Pedro M. Dor musculoesquelética em membros inferiores de pacientes obesos antes e depois da cirurgia bariátrica. ABCD Arq Bras Cir Digestiva. 2012;25(1):29-32. Acta Paul Enferm. 2014; 27(2):157-64. 163 Quality of life before and after bariatric surgery 15. Soccol FB, Peruzzo SS, Mortari D, Scortegagna G, Sbruzzi G, Santos PC Rockenbach CW, Leguisamo CP. Prevalência de artralgia em indivíduos obesos no pré e pós-operatório tardio de cirurgia bariátrica. Scientia Medica. 2009;19(2):69-74. 164 18. Wijhoven H, De Vet H, Picavet S. Explaining sex differences in chronic musculoskeletal pain in general population. Pain. 2006;124(4):15866. 16.Sá K, Baptista AF, Matos MA, Lessa I. Prevalência de dor crônica e fatores associados na população de Salvador, Bahia. Rev Bras Ortop. 2008;43(3):96-102. 19.Serrano AQ, Vasconcelos MGL, Silva GA, Cerqueira MM, Pontes CM. Percepção do adolescente obeso sobre as repercussões da obesidade em sua saúde. Rev Esc Enferm USP; 2010;44(1):2531. 17.Leveille SG, Zhang Y, McMullen W, Kelly-Hayes M, Felson D. Sex differences in musculoskeletal pain in older adults. Pain. 2005;3(116):332-8. 20.Gordon PC, Kaio GH, Sallet PC. Aspectos do acompanhamento psiquiátrico de pacientes obesos sob tratamento bariátrico: revisão. Rev Psiquiatr Clínica. 2011;38(4):148-54. Acta Paul Enferm. 2014; 27(2):157-64. Original Article Smoking, alcohol consumption and physical activity: associations in acute coronary syndrome Tabagismo, consumo de álcool e atividade física: associações na síndrome coronariana aguda Evelise Helena Fadini Reis Brunori1,3 Agueda Maria Ruiz Zimmer Cavalcante1,3 Camila Takao Lopes2,3 Juliana de Lima Lopes3 Alba Lucia Bottura Leite de Barros3 Keywords Smoking/adverse effects; Alcohol drinking/adverse effects; Exercise; Acute coronary syndrome; Risk factors; Nursing assessment Descritores Hábito de fumar/efeitos adversos; Consumo de bebidas alcoólicas/ efeitos adversos; Exercício; Síndrome coronariana aguda; Fatores de risco; Avaliação em enfermagem Submitted February 16, 2014 Accepted March 31, 2014 Corresponding author Alba Lucia Bottura Leite de Barros Napoleão de Barros street, 754, Vila Clementino, São Paulo, SP, Brazil. Zip Code: 04024-002 [email protected] Abstract Objective: To describe the prevalence of smoking and alcohol consumption; to identify the level of physical activity; the degree of nicotine and alcohol dependence and the association between these risk factors in subjects with acute coronary syndrome. Methods: Cross-sectional study with 150 patients with acute coronary syndrome. For data collection, interviews, analysis of patients’ charts and validated questionnaires on smoking, alcohol consumption and physical activity were used. Results: 58.7% were smokers (35.2% high dependence), 42% consumed alcohol (65.1% low risk), 36.7% were active. Smoking was significantly correlated to alcohol consumption and high nicotine dependence was associated with sedentary lifestyles. Conclusion: There was high prevalence of smoking and alcohol consumption. There was a high nicotine dependence and low risk alcohol consumption. Most participants were active. There was a correlation between alcohol consumption and smoking, as well as association of high nicotine dependence with sedentary lifestyles. Resumo Objetivo: Descrever a prevalência de tabagismo e consumo de álcool; identificar o nível de atividade física; os graus de dependência de nicotina e álcool e verificar a associação entre esses fatores de risco em indivíduos com síndrome coronariana aguda. Métodos: Estudo transversal com 150 pacientes com síndrome coronariana aguda. Para coleta de dados, foram utilizadas entrevistas, análise de prontuários e questionários validados sobre tabagismo, consumo de álcool e atividade física. Resultados: 58.7% eram fumantes (35,2% alta dependência), 42% consumiam álcool (65,1% baixo risco), 36,7% eram ativos. O tabagismo correlacionou-se significativamente ao consumo de álcool e a alta dependência de nicotina associou-se ao sedentarismo. Conclusão: Houve alta prevalência de tabagismo e consumo de álcool. Observou-se elevada dependência de nicotina e consumo de álcool de baixo risco. A maioria dos entrevistados era ativa. Houve correlação entre consumo de álcool e tabagismo, assim como associação da alta dependência de nicotina com sedentarismo. Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil. Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brazil. 3 Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil. Conflict of interest: there are no conflicts of interest to be declared. 1 DOI http://dx.doi.org/10.1590/19820194201400029 2 Acta Paul Enferm. 2014; 27(2):165-72. 165 Smoking, alcohol consumption and physical activity: associations in acute coronary syndrome Introduction The growing prevalence rate of chronic non-communicable diseases in Brazil and in the world is alarming, since they generate disabilities and diminish quality of life due to the debilitation of the individual, keeping them, in many cases, bedridden and under long hospitalizations. In every three deaths, two are caused by non-communicable chronic diseases.(1) Among these diseases, cardiovascular are the leading cause of mortality in Brazil and worldwide. It is estimated that by 2020, cardiovascular diseases will cause about 25 million deaths, 19 million of them in low- and middle-income countries.(2) The increased mortality is directly associated with the presence or absence of risk factors and other concomitant diseases, which influence the predisposition of the individual to develop complications and it will generate chronic diseases, which are more healthily compromising.(3) The modification of one or more health risk factors benefits health, significantly reducing morbidity and mortality from heart disease and coronary events. Moreover, it contributes to the improvement of symptoms, general well-being and quality of life.(2-4) Information about certain groups of risk factors may address the development of intervention programs. Among hypertensive subjects, for example, the prevalence of other cardiovascular risk factors are high. The grouping of some of these factors are associated with the need for greater number of antihypertensive drugs.(5) Risk factors for cardiovascular disease have received particular attention from governmental organizations, and health systems, providing priority attention to the reduction of chronic diseases.(6) The modifiable risk factors such as smoking, physical inactivity, unhealthy diets and the harmful use of alcohol - we highlight the possibility of being minimized from the pursuit of healthy behaviors acquired by the individual. Some of these factors are shared among individuals with different chronic non-communicable diseases, and might influence the onset of acute coronary syndrome.(4) 166 Acta Paul Enferm. 2014; 27(2):165-72. Although modifiable, alterations of such risk factors are challenging. A year after coronary artery bypass surgery of 320 individuals, we found that only 9% of smokers had stopped the habit, abdominal obesity had increased 8% and they did not observe changes in eating habits and exercise patterns.(7) Concerned about the increase of non-communicable chronic diseases, with the impact generated in the country health system and the healthy development of society, the World Health Organization developed a set of targets and indicators that seek, above all, prevention and control of these diseases and their risk factors.(6) This concern is also shared by health professionals, who are urged to seek risk factors in different populations, in order to offer health education and reduce the incidence of these diseases. Considering the high prevalence and associated mortality to worldwide non-communicable chronic diseases, particularly cardiovascular diseases, as well as the objectives established by the World Health Organization for the prevention and control of these diseases and their risk factors, knowledge of the concomitant presence of features that increase the risk of developing acute coronary syndrome is essential at all levels of care. Based on the above, the objectives of this study were to describe the prevalence of smoking and alcohol consumption; identify the level of physical activity; the degree of nicotine and alcohol dependence and the association between these risk factors in subjects with acute coronary syndrome. Methods This is a cross-sectional study conducted in the Cardiologic Intensive Care Unit and Cardiac Inpatient Unit of a large tertiary teaching hospital located in the capital of the state of Sao Paulo, southeastern Brazil. The sample size was obtained by the Z-test, with normal distribution, with an estimated proportion regarding the population of interest to a significance level of 5% and 90% sample power. The minimum sample size was 138 patients. Brunori EH, Cavalcante AM, Lopes CT, Lopes JL, Barros AL Patients aged greater than 18 years and hospitalized for the first time due to acute coronary syndrome were included in the study. Patients with acute pain, dyspnea or symptomatic hypotension at the time of data collection were excluded because of the discomfort they might experience during the interview. Data were collected between September 2011 to May 2012, through interviews, patients’ charts analysis and the use of an instrument developed by the authors composed of three parts: demographic information (gender, age), clinical variables (medical diagnosis) and risk factors related to lifestyle (smoking, alcohol dependence and physical activity). Risk factors were assessed using internationally validated questionnaires. The nicotine dependence was assessed using the Fagerström Nicotine Dependence Test. This is the most recognized and used test in the detection of nicotine dependence among smokers, composed of six questions. The degree of nicotine dependence is determined by the sum of the responses, with scores ranging from 0-10 points. To assess patients, we used the following categorization: 0-2 points: very low dependence; 3-4 points: low dependence; 5 points: average dependence; 6-7 points: high dependence; 8-10 points: very high dependence.(8) To assess alcohol consumption, the Alcohol Use Disorders Identification Test developed by the World Health Organization was used to identify the dependence of its consumption and severity in the last year. The questionnaire contains ten questions, each with four alternatives, with scores for each item ranging from zero to four points, totaling zero to 40 points. The patients are classified as: low risk (<7 points); risk (8-15 points); high risk (16-19 points); possible dependence (>20 points).(9) Physical activity was assessed by the International Physical Activity Questionnaire, long version - developed by the World Health Organization and the Centers for Disease Control and Prevention. This instrument assesses physical activity undertaken by the individual in five different domains related to work, transport, do- mestic and gardening activities, recreation, sport and leisure time. The absolute intensity of physical activity reflects the rate of energy expenditure during exercise and is expressed in metabolic equivalents (METs), where 1 MET equals the resting metabolic rate of approximately 3.5 mL O2/kg/min.(10) We considered the energy expenditure in METs for each activity that composed the five domains. After calculating the energy expenditure of each domain, the values of each individual were summed up, and the results enabled us to stratify the patient as very active, active, irregularly active and sedentary. Individuals considered very active were those that met the recommendations to achieve a total minimum of 1500 MET-min/week with vigorous activity ≥5 days/week for ≥30 minutes per session or vigorous activity ≥3 days/week for ≥20 minutes associated to moderate activity or walking ≥ 5days/ week for ≥30minutes per session. We also considered very active the individuals who had any added activity ≥7 days/week, reaching a minimum total of 3000 MET-min/week. Individuals considered active were those who fulfilled the recommendations of performing vigorous activity ≥3 days/week for ≥20 minutes per session; moderate activity or walking ≥5 days/week for ≥30minutes per session; or any activity added ≥5days/week, ≥150 minutes/week (walking plus moderate activity plus vigorous activity), reaching a minimum total of 600 METmin/week. Individuals considered irregularly active were those who practiced physical activity, however, insufficient to be classified as active, because they did not meet the recommendations regarding the frequency or duration. To perform this classification, we added the frequency and duration of different types of activities (walking plus the moderate and vigorous activities). Individuals considered sedentary were those who did not perform any physical activity for at least 10 continuous minutes during the week. Data were analyzed using SPSS (Statistical Package for Social Sciences) version 19. DescripActa Paul Enferm. 2014; 27(2):165-72. 167 Smoking, alcohol consumption and physical activity: associations in acute coronary syndrome tive statistics frequencies (absolute and relative) were used for qualitative measurements. Summary statistics of mean, median, standard deviation and percentiles were used for quantitative measurements. The relationship between ordinal and quantitative measures (scores) of smoking, physical activity and alcohol consumption were assessed using the Spearman correlation coefficient. The association between qualitative measures were assessed using the chi square test of Fisher or Pearson. The results were evaluated with a confidence interval of 95%, and the statistical significance established at p<0.05. The study development followed the national and international standards of ethics in research involving human beings. Table 1. Rate of alcohol consumption, nicotine dependence and physical activity of individuals hospitalized for acute coronary syndrome Classification n(%) Alcohol Consumption Low Risk 41(65.1) Risk 12(19.1) High Risk 6(9.5) Probable dependence 4(6.3) Nicotine Dependence Very low 5(5.7) Low 10(11.4) Average 13(14.7) High 31(35.2) Very High 29(33.0) Physical activity Results One hundred and fifty patients were included in the study, these were hospitalized due to an acute myocardial infarction with ST segment elevation (n=109; 72.7%), unstable angina (n=19; 14.7%) and acute myocardial infarction without ST segment elevation (n=19; 12.7%). The majority were male (72.7%) with mean age of 57.51±11.23 years. Sixty-three patients (42%) reported alcohol consumption. In most cases, consumption was considered low risk (65.1%) (Table 1). The average consumption score was 7.67±7.07 (low risk), with a minimum of one and maximum of 31. Eighty-eight patients (58.7%) smoked, of which 35.2% had a high degree of dependence on nicotine and 33% had a very high dependence (Table 1). The dependence average score was 6.29±2.08 (high dependence), with a minimum of one and maximum of ten. With regard to physical activity, the majority of participants were considered active (36.7%) and only 15.3% were ranked as sedentary people (Table 1). Among patients who consumed alcohol, there was a weak (r<0.3) but significant (p<0.05) correlation with smoking. There was no significant correlation between other RF (Table 2). 168 Acta Paul Enferm. 2014; 27(2):165-72. Sedentary 23(15.3) Irregularly active 40(26.7) Active 55(36.7) Very active 32(21.3) For the classification of alcohol consumption, n=63; for classification of nicotine dependence, n=88; for classification of physical activity, n=150 Table 2. Correlation between smoking, alcohol consumption and frequency of physical activity in individuals hospitalized for acute coronary syndrome Smoking Physical Activity Physical Activity Alcohol consumption r 0.088 0.284 p 0.284 0.024 r 0.156 p 0.221 For the classification of alcohol consumption, n=63; for classification of nicotine dependence, n=88; for classification of physical activity, n=150 Weak evidence of an association between nicotine dependence scores and levels of physical activity (p <0.10) were found. There was a greater proportion of average nicotine dependence in the very active group (18.8%), and high nicotine dependence in the sedentary group (Table 3). There was no significant association between the scores of nicotine dependence and alcohol consumption (p=0.620). Levels of physical activity and alcohol consumption were also not significantly associated (p=0.726). Brunori EH, Cavalcante AM, Lopes CT, Lopes JL, Barros AL Table 3. Association between the level of nicotine dependence and frequency of physical activity in individuals hospitalized for acute coronary syndrome Physical Activity Nicotine Dependence Does not smoke Very low Low Very active n(%) Active n(%) Irregularly active n(%) Sedentary n(%) Total n(%) 13(40.6) 24(43.6) 17(42.5) 7(30.4) 61(40.7) 1(3.1) 4(7.3) 1(2.5) 0(0) 6(4.0) 0(0) 4(7.3) 5(12.5) 1(4.3) 10(6.7) Average 6(18.8) 3(5.5) 4(10.0) 0(0) 13(8.7) High 6(18.8) 13(23.6) 3(7.5) 9(39.1) 31(20.7) Very high 6(18.8) 7(12.7) 10(25.0) 6(26.1) 29(19.3) Total 32(100) 55(100) 40(100) 23(100) 150(100) p=0.056 (Fisher) Discussion The results of this study are limited by its cross-sectional design, since no causal relationship between the risk factors can be established. However, important information that differentiates the studied individuals in the general population were revealed. The characteristics and associations investigated in this study contribute to the expansion of knowledge about the differential grouping of risk factors for cardiovascular disease. Since nurses are placed in the context of health education, such information also supports the planning of interventions directed at the main risk factor, smoking. When implemented such interventions, it is expected that there is also a positive impact of harmful alcohol consumption and physical activity level. Alcohol dependence in the Brazilian population is increasing. Research conducted with more than 200,000 inhabitants in 107 Brazilian cities in 2001 and 2005 show that alcohol consumption in the general population increased from 11.2% to 12.3%.(11) In the present study, the prevalence of alcohol consumption was 3.4 times higher than that of the general population. However, most patients had low risk of dependence, suggesting that this risk factor may not have significantly contributed to the acute coronary syndrome. In fact, when consumed daily in low to moderate doses (15g of ethanol for women and 15 to 30g of ethanol for men) it is associated with cardio-protection.(12) However, one of the factors associated with reduced chance of smoking cessation is current consumption of alcohol. In a prospective cohort of 4832 individuals, those who consumed four or more drinks once or more per week (considered heavy consumption) had lower rates of smoking cessation compared to the other participants.(13) The results of the current research show a positive correlation between smoking and alcohol consumption, especially in subjects with high nicotine dependence and moderate consumption of alcohol. These results corroborate previous findings that, even in the absence of alcohol dependence, there is a strong positive linear relationship between greater alcohol involvement and increased chance of progression of smoking as a sporadic practice into a daily habit and nicotine addiction.(14) Most patients with cardiovascular disease continues to smoke after acute myocardial infarction, exposing themselves to a 50.0% increased risk of recurrent coronary events among nonsmokers.(15) In Brazil, the population of smokers is 14.8%, with a higher prevalence among men.(16) Among the individuals evaluated in this study, the prevalence of smoking was almost four times higher than that of the general population, with a predominance of high and very high dependence, suggesting that RF may have played a crucial role in the development of acute coronary syndrome. Sedentarism was the most prevalent risk factor (86.8%) among 152 patients with acute coronary syndrome treated in an emergency department. (17) Regular physical activity is recommended in both primary prevention and secondary prevention of coronary artery disease. A program of aerobic exercise three times a week involving treadmill, bike or walking exercise lasting 45 minutes for six weeks significantly reduced the inflammatory status of 52 patients with coronary artery disease and was associated with improved body mass index.(18) Acta Paul Enferm. 2014; 27(2):165-72. 169 Smoking, alcohol consumption and physical activity: associations in acute coronary syndrome However, among the patients in our sample, more than 50.0% were considered active. This result approximates to that of the general population of the state capitals of Brazil, where 76% of the adult population is active in at least one of the domains of physical activity (leisure, work, domestic and gardening activities or transport).(19) Although most have been considered active, it may be suggested, based on the assessment of the existence of associations between the risk factors, the greater nicotine intake leads to sedentary lifestyle, or sedentary lifestyle leads to increased nicotine dependence. Approximately 60.0% of patients who had an acute myocardial infarction or other coronary event are at high risk for developing a new event. The presence of risk factors increase susceptibility. Thus, it was demonstrated that smoking cessation, consumption of fruits and vegetables and exercise regimes together may decrease the relative risk of acute myocardial infarction in up to 80.0%.(20) Changes in risk factors for cardiovascular disease may have global impact. From 1991 to 2005, there was a significant reduction in deaths from coronary heart disease in the world. It is noteworthy that 54.0% of the decline in mortality were attributed to changes in risk factors, especially the reduction of the concentration of total cholesterol and an increase in physical activity. Blood pressure levels decreased in females, which explained the decrease in mortality in 29.0% and about 15.0% of the decline in mortality rate was attributed to the reduction of smoking in males.(21) Despite the high risk for cardiovascular disease is present in only 10.0% of the population, there is a group of people from intermediate and low risk factors who are more prone to cardiovascular events. As a result, 90.0% or more cardiovascular events occur in people with one or more risk factors. This population would not qualify for intensive and invasive procedures, but they would benefit from the reduction of risk factors through changes in lifestyle and consequent reduction in risk of cardiovascular events. Therefore, we understand as keystones for the lower rates of morbidity, 170 Acta Paul Enferm. 2014; 27(2):165-72. for the maintenance of life and the reduction of comorbidities, the urgent implementation of educational measures.(22) The primary and secondary prevention should be a priority in assistance to individuals with risk factors for the development of acute coronary syndrome, and other chronic non-communicable diseases.(22) One of the key challenges facing public health professionals are the difficulties we face when developing intervention programs that address multiple risk factors, since there are infinite combinations of RF that each patient can have.(23) Three studies (EUROpean Action on Secondary Prevention through Intervention to Reduce Events - EUROASPIRE I, II , III) investigated the temporal trends of cardiovascular risk factors in patients previously hospitalized for coronary artery disease, they demonstrated that the recommendations for the control of cardiovascular risk factors have not been implemented in clinical practice and show the urgent need to strengthen prevention strategies in patients with coronary artery disease.(24) Behavioral modification should have similar priority to drug therapy immediately after acute coronary syndrome. A population study followed 18809 patients from 41 countries up to 6 months after hospitalization for acute coronary syndrome. Patients who reported continuing smoking and lack of adherence to diet and exercise had a 3.8 times greater chance of myocardial infarction, stroke or death compared to non-smokers who modified their diet and exercise pattern within six months.(25) Many studies have important results for patients in secondary prevention who receive educational interventions. Among 1510 patients hospitalized for acute coronary syndrome followed for six months, there was a mean reduction in body mass index, waist circumference and increased regular physical activity in the group that received an intervention. (21) In Italy, an implemented educational program by nurses for hypertensive patients significantly improved obesity, low fruit consumption, uncontrolled hypertension, LDL and total cholesterol.(26) Brunori EH, Cavalcante AM, Lopes CT, Lopes JL, Barros AL Conclusion There was a high prevalence of smoking and alcohol consumption, nicotine dependence was high, alcohol consumption was low risk. Most individuals were active. There was a significant correlation between alcohol dependence and smoking. The high nicotine dependence was significantly associated with sedentary lifestyles. Acknowledgements Research conducted with support from the National Council for Scientific and Technological Development (CNPq), process 301688/2009-5. Collaborations Brunori EHFR contributed to project design, analysis and interpretation of data and writing the paper. AMRZ Cavalcante and Lopes CT contributed to the analysis and interpretation of data and writing of the paper. Lopes JL and Barros ALBL participated in the project design, analysis and interpretation of data, critical review of the relevant intellectual content and final approval of the version to be published. References 1. Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria P, et al. Priority actions for the non-communicable disease crisis. Lancet. 2011; 377:1438–47. smoking index in a general population survey. BMC Public Health. 2009;9:493-7. 9. Jomar RT, Paixão LA, Abreu AM. Alcohol Use Disorders Identification Test (AUDIT) e sua aplicabilidade na atenção primária à saúde. Rev APS. 2012;15(1):113-7. 10.Lee PH, Macfarlane DJ, Lam TH, Stewart SM. Validity of the international physical activity questionnaire short form (IPAQSF): A systematic review. Int J Behav Nutrit Physical Activity. 2011;8:115-26. 11.Fonseca AM, Galduroz JC, Noto AR, Carlini EL. Comparison between two household surveys on psychotropic drug use in Brazil: 2001 and 2004. Ciênc Saúde Coletiva. 2010;15(3): 663-70. 12.Ronksley PE, Brien SE, Turner BJ, Mukamal KJ, Ghali WA. Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis. BMJ. 2011;342:d671-83. 13. Kahler CW, Borland R, Hyland A, McKee SA, Thompson ME, Cummings KM. Alcohol consumption and quitting smoking in the International Tobacco Control (ITC) Four Country Survey. Drug Alcohol Depend. 2009;100(3):214–20. 14.Kahler CW, Strong DR, Papandonatos GD, Colby SM, Clark MA, Boergers J, et al. Cigarette smoking and the lifetime alcohol involvement continuum. Drug Alcohol Depend. 2008; 93(12):111–20. 15. Kim HE, Song YM, Kim BK, Park YS, Kim MH. Factors associated with persistent smoking after the diagnosis of cardiovascular disease. Korean J Fam Med. 2013;34(3):160-8. 16.Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde, Secretaria de Gestão Estratégia e Participativa. [Vigitel Brazil 2010: Monitoring System of Risk and Protective Factors for Non Communicable Chronic Diseases by Telephone Survey]. Ministério da Saúde, Brasília [Internet]. 2011. [cited 2013 Dec 12] Available from: http://bvsms.saude.gov.br/bvs/publicacoes/vigitel_2010.pdf. Portuguese. 17. Lemos KF, Davis R, Moraes MA, Azzolin K. [Prevalence of risk factors for acute coronary syndrome in patients treated in an emergency]. Rev Gaúcha Enferm. 2010; 31(1):129-35. Portuguese. 2. Servinc S, Akyol AD. Cardiac risk factors and quality of life in patients with coronary artery disease. J Clin Nurs. 2010;19(9-10):1315–25. 18.Ranković G, Miličić B, Savić T, Đinđić B, Mančev Z, Pešić G Effects of physical exercise on inflammatory parameters and risk for repeated acute coronary syndrome in patients with ischemic heart disease. Vojnosanit Pregl. 2009;66(1):44-8. 3. Chan CW, Perry L. Lifestyle health promotion interventions for the nursing workforce: a systematic review. J Clin Nurs. 2012; 21(1516):2247-61. 19.Florindo AA, Hallal PC, Moura EC, Malta DC. Practice of physical activities and associated factors in adults, Brazil, 2006. Rev Saúde Pública. 2009;43(Supl 2):65-73. 4. Marrero SL, Bloom DE, Adashi EY. Noncommunicable diseases. A global health crisis in a new world order. J Am Med Assoc. 2012; 307(19): 2037-8. 20. Kãner A, Nilsson S, Jaarsma T, Andersson A, Wiréhn A-B, Wodlin P, et al. The effect of problem-based learning in patient education after an event of CORONARY heart disease- a randomized study in PRIMARY health care: design and methodology of the COR-PRIM study. BMC Fam Pract. 2012;13:110-8. 5. Ohta Y, Tsuchihashi T, Onaka U, Hasegawa E. Clustering of cardiovascular risk factors and blood pressure control status in hypertensive patients. Intern Med. 2010; 49(15):1483-7. 6. World Health Organization. Reducing risks and preventing disease: population-wide interventions. [Internet]. 2011[cited 2013 Jun 17]. Available from: http://www.who.int/nmh/publications/ncd_report_chapter4.pdf. 7. Pomeshkina S, Borovik IV, Barbarash OL. Adherence to non-medication treatment in patients undergoing coronary artery bypass surgery. Eur Heart J. 2013;34 (Suppl 1):1213-8. 8. Pérez-Ríos M, Santiago-Pérez MI, Alonso B, Malvar A, Hervada X, Leon J. Fagerstrom test for nicotine dependence vs heavy 21. Muñiz J, Doblas GJJ, Pérez SMI, Goya LI, Eizagaetxebarría MN, Galván TE, et al. The effect of post-discharge educational intervention on patients in achieving objectives in modifiable risk factors six months after discharge following an episode of acute coronary syndrome (CAM-2 Project): a randomized controlled trial. Health Qual Life Outcom. 2010; 8:137-45. 22.Kones R. Primary prevention of coronary heart disease integration of new data, evolving views, revised goal, and role of rosuvastatin in management. A comprehensive survey. Drug Des Devel Ther. 2011;5: 325-80. Acta Paul Enferm. 2014; 27(2):165-72. 171 Smoking, alcohol consumption and physical activity: associations in acute coronary syndrome 23.Leventhal AM, Huh J, Dunton GF. Clustering of modifiable biobehavioral risk factors for chronic disease in US adults: a latent class analysis. Perspect Public Health. [Internet]. 2013[cited 2013 Dec 02]. Available from: http://rsh.sagepub.com/content/ early/2013/08/02/1757913913495780.long. 24.Prugger C, Heidrich J, Wellmann J, Dittrich R, Brand SM, Telgmann R, et al. Trends in cardiovascular risk factors among patients with coronary heart disease. Dtsch Arztebl Int. 2012;109(17):303-10. 172 Acta Paul Enferm. 2014; 27(2):165-72. 25. Chow CK, Jolly S, Rao-Melacini P, Fox KA, Anand AA, Yusuf S. Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes. Circulation. 2010;121(6):750-8. 26.Cicolini G, Simonetti V, Comparcini D, Celiberti I, Di Nicola M, Capasso LM, et al. Efficacy of a nurse-led email reminder program for cardiovascular prevention risk reduction in hypertensive patients: A randomized controlled trial. Int J Nurs Stud. 2013 Oct 25. pii: S00207489(13)00302-7. Original Article Content validation of the nursing intervention called Environmental Control: worker safety Validação de conteúdo da intervenção de enfermagem Controle Ambiental: segurança do trabalhador Francisca Sánchez-Ayllón1 Adriana Catarina de Souza Oliveira1 Isabel Morales1 Jéssica Dantas de Sá2 Paloma Echevarría Pérez1 Keywords Classification nursing; Validation studies; Occupational health; Environmental health; Occupational health nursing Descritores Classificação de enfermagem; Estudos de validação; Saúde do trabalhador; Saúde ambiental; Enfermagem do trabalho Submitted March 17, 2014 Accepted April 14, 2014 Corresponding author Francisca Sánchez Ayllón Campus de Los Jerónimos, unnumbered, 30107, Murcia, Spain. [email protected] DOI http://dx.doi.org/10.1590/19820194201400030 Abstract Objective: Validating the content of the nursing intervention called Environmental Control: worker safety in Spain. Methods: An exploratory and descriptive study using the Fehring method associated with the Delphi method and a sample of 11 experts in occupational nursing. For the clarity of definition and the activities was used a scale ranging from confusing (1) and clear (7) or vaguely (1) and exactly (7). A Likert scale (1 - totally disagree /5 - totally agree) was used for the nursing action and the need of the activity for its intervention. Results: The nursing action was considered as critical with the mean score of 0.86% (SD=0.23) and 73 % of the experts considered that the title of the intervention exactly identifies the contents of the definition. Conclusion: The intervention was considered valid for occupational health with the need for practical applicability using a system of classification specific for occupational health nursing, with the Nursing Process implementation. Resumo Objetivo: Validar o conteúdo da intervenção de enfermagem Controle Ambiental: segurança do trabalhador na Espanha. Métodos: Estudo exploratório e descritivo, utilizando o método Fehring associado ao método Delphi. Amostra de 11 especialistas em enfermagem do trabalho. Para a clareza da definição e das atividades, foi utilizada Escala variando entre confusa (1) e clara (7) ou vagamente (1) e exatamente (7). Para ação de enfermagem e a necessidade da atividade para sua intervenção, atribuímos Escala Likert (1- totalmente em desacordo / 5- totalmente de acordo). Resultados: A ação de enfermagem foi considerada crítica com pontuação média de 0,86% (DV=0,23), 73% dos expertos consideraram que o título da intervenção identifica exatamente o conteúdo da definição. Conclusão: A intervenção foi considerada válida para a saúde laboral, com a necessidade da aplicabilidade prática utilizando um sistema de classificação próprio da enfermagem na saúde laboral, com a implementação do Processo de Enfermagem. 1 Facultad de Enfermería, Universidad Católica de Murcia, Murcia, Spain. 2Faculdade de Enfermagem, Universidade Federal do Rio Grande do Norte, Natal, Brazil. Conflicts of interest: no conflicts of interest to declare. Acta Paul Enferm. 2014; 27(2):173-8. 173 Content validation of the nursing intervention called Environmental Control: worker safety Introduction The effective implementation of the nursing process points to the need for a standardized language of the profession, present in all stages of this methodology. The use of taxonomies in nursing allows a common language, providing communication between nursing professionals and professionals from other areas, and culminating in quality care with scientific support, from the use of concrete, meaningful and reliable data for clinical practice. In this sense, the Nursing Intervention Classification - NIC stands out as a useful taxonomy in clinical documentation, communication of care, integration of data in information systems, being used in various clinics and institutions as a source of research data, as well as allowing the measurement of productivity and assessment of the competence of nurses. In order to act in occupational health, the nursing process is an important tool that allows critical thinking about the risks or potential problems that a particular worker can present in a certain working condition. A safe and evidence-based nursing intervention favors this care. The impact of problems due to inadequate working conditions and/or inadequate occupational health is considered important because these factors result in high rates of absenteeism, as well as disorders in the quality of life of these professionals. An average 120 million injuries per year occur as result of accidents at work; 200,000 work dysfunctions, and between 68 and 157 million cases of occupational diseases worldwide. A precarious occupational health reduces the ability of professionals, with presented losses that can reach between 10 and 20% of the Gross Domestic Product of a country. Around the world, such losses can reach 4% of gross domestic product related to deaths, illnesses and labor dysfunctions.(1) In Spain, the role of nurses in occupational health is defined as a specialty from the perspective of approach of workers’ state in all its dimensions. Within a multidimensional care to the employee, stands out the nursing intervention proposed by the NIC taxonomy called Environmental Control: worker safety, because nurses have a great role in re- 174 Acta Paul Enferm. 2014; 27(2):173-8. lation to observing the risks and promoting changes in the work environment. The interaction of the environment on the health of individuals brings them great risks, and it stands out the need to organize and perform actions aiming to prevent or reduce such effects. This need is visible due to the occurrence of 569 fatal accidents in the work journey, which represents 0.1% of work accidents with sickness leave this year, and with non-traumatic diseases - such as heart attack and cerebrovascular accident - as the most frequent cause. In Spain, specific health surveillance protocols are used, however, the nursing process with regard to nursing classification systems, is not contemplated in any stage of health surveillance, thus emerging the need for incorporating and adapting such methodology to these action guides.(2) The aim of this study was to validate the contents of the nursing intervention called Environmental Control: worker safety in Spain. Methods This is an exploratory and descriptive study, using the Fehring method associated with the Delphi method.(3,4) Furthermore, we followed the directions of the Normalización de las Intervenciones para la Práctica de Enfermería – NIPE project for the validation of a nursing intervention.(4) The study was developed in the context of occupational health nursing in Spain, together with the services of occupational risks prevention. It was carried out between June 2012 and April 2013. Initially the Delphi method was used, from inquiries with a number of experts on this intervention. The population consisted of nurses from the services of occupational risks prevention in Spain. The sample consisted of 11 nurses, selected through an intentional procedure, which fulfilled the inclusion criteria based on the method of Fehring, which proposes carrying out a standardized scheme, based on the opinion of experts. For the selection of experts, at first, a literature review was carried out from June 2012 to December 2012, in an attempt to identify experts through Sánchez-Ayllón F, Oliveira AC, Morales I, Sá JD, Pérez PE publications involving the nursing process and occupational health in Spain. The following database were used as the search strategy: MEDLINE, CUIDEN PLUS, CUIDATGE, and ELSEVIER, as well as publications in the poster format from the congresses of AENTDE (Asociación Española de Nomenclatura, Taxonomía y Diagnósticos de Enfermería) and Occupational Risk Prevention in 2012. The used descriptors were: Nursing diagnosis in occupational health; North American Nursing Diagnosis Association (NANDA-International), NIC and Nursing Outcomes Clasification (NOC) in occupational health; and Nursing Process in occupational health. Papers that related the Nursing Process within the context of occupational health were selected. The authors of such articles and/or posters were contacted with the invitation to participate in the validation process. Initially, a cover letter and a questionnaire adapted to the Spanish context were sent to evaluate whether the professional should be considered an expert in this area, which has a fourth additional point, that is to meet at least one of the following requirements: be working or have worked in the area of occupational health for at least 6 months; Having specific training in occupational health (MSc in occupational health, nursing in occupational health specialty); Having scientific production in the field of occupational health. The sample consisted of 11 experts who positively attested the questionnaire sent. After the selection of experts, as well as their acceptance in participating of the study, a questionnaire was sent electronically. It consisted of open and closed question addressing the nursing intervention of NIC Environmental Control: Worker Safety. The questionnaire was divided into three parts. The first set of questions showed the assessment of the intervention definition indicated by the NIC, evaluating from a numerical scale, if the definition describes a nursing action, if it is clear and if the title of the intervention allows identifying the content of the definition. The second part included the evaluation of each of the activities of the intervention presented in the taxonomy, assessing the need to carry out such activity in order to make the proposed in- tervention, and regarding the clarity of the activity description. The third part allowed the experts to add some activity they considered relevant to the scope of intervention that was not in the NIC. Regarding the clarity of the definitions and the activities, as well as the identification of the definition by title, it was used a global scale with scores 1-7, ranging from confusing (1) and clear (7) or vaguely (1) and exactly (7). For the questions as to whether the definition describes a nursing action and the need for the activity to implement the intervention, a Likert scale was used: 1- completely disagree → 5- totally agree. The data obtained after evaluation of the experts were statistically analyzed with the use of Statistical Package for the Social Sciences (SPSS) version 16.0. Data interpretation was based on the method proposed by Fehring, where the value given by each expert for each activity and definition had a weight, from the proposed Likert scale, as follows: 1=0; 2=0.25; 3=0.50; 4=0.75 and 5=1, so that the maximum value reached is one (1), from the mean of each expert. Values greater than or equal to 0.80 were considered as critical due to its great representation for the experts, the activities with values between 0.79 and 0.50 were denominated as minor for having lower scores, and values lower than 0.50 were disregarded because of its diminished representativeness. For the global scale ranging from 1 to 7, the values 1 and 2 were grouped for the variables confusing or vaguely; 3, 4 and 5 were named as indifferent; and the values 6 and 7 were considered as clear or exactly, and presented as percentage. The development of the study met the national and international standards of ethics in research involving human beings. Results Regarding the question if the definition describes a nursing action, the experts have identified a mean score of 0.86, considered as critical. The standard deviation was 0.23. The definition was considered clear for 73% of experts, 18% Acta Paul Enferm. 2014; 27(2):173-8. 175 Content validation of the nursing intervention called Environmental Control: worker safety were indifferent about its clarity, and 9% considered it confusing. Also, 73% of experts considered that the title of the intervention identifies the exact content of the definition, with 18% indifferent, and 9% who judged that it vaguely expresses the content of the definition. Experts gave their opinion regarding the activities suggested by the intervention in order to reach it, as shown in table 1. Table 1. Validation of intervention activities - Environmental Control: Worker safety - as to its necessity and clarity NIC activities Necessity Clarity Score SD % Keeping confidential records of the employees’ health. 0.91 0.17 82 Determining the physical status of employees for working. 0.98 0.8 82 Identifying the risks and stressors in the work environment (physical, biological, chemical and ergonomic). 0.98 0.8 91 Determining the applicable standards of health and safety at work, as well as its compliance in the workplace. 0.93 0.12 82 Informing workers of their rights and obligations according to the department of health and safety at work. 0.93 0.16 91 Informing workers about the substances to which they may be exposed. 0.98 0.08 64 Using labels and posters to warn workers about the potential hazards of their workplace. 0.91 0.13 73 Keeping records of injuries and illnesses at work in acceptable forms to the department of health and safety, and participating in the inspection of this department. 0.93 0.12 91 Making records of injuries and illnesses of workers. 0.95 0.1 82 Identifying the risk factors of injuries and diseases at work by reviewing its standards in the records. 0.93 0.23 82 Starting the environmental modification to eliminate or minimize risks. 0.98 0.08 64 Setting investigation programs in motion in the workplace for the early detection of injuries and nonprofessional illnesses, but related to work. 0.98 0.08 100 Setting programs in motion to promote health in the workplace in relation to the assessment of health risks. 0.98 0.08 64 Developing emergency protocols and preparing selected employees for emergency care. 0.95 0.1 55 Coordinating the follow-up of care and injuries and illnesses related to work. 0.93 0.16 73 SD = Standard Deviation The activities were judged as critical by the experts in relation to the need for implementing the intervention, and all had a score higher than 0.9. Regarding the clarity of the activities, it was judged as clear, i.e., achieved a score between 6 and 7 by at least 55% of the experts. Regarding the inclusion of activities that are not present in the activities standardized by the NIC, 91% of experts have proposed activities. 176 Acta Paul Enferm. 2014; 27(2):173-8. These were categorized by the authors and are presented as follows: Identifying and protecting the especially sensitive workers (45.5%); Informing about preventive measures (individual and collective protection equipment, organizational measures) and occupational risk prevention (36.5%); Applying specific nursing techniques for the correct evaluation of workers’ health (27.5%); Carrying out health surveillance in accordance with the protocols of health monitoring of the ministry for each job position (27.5%); Verifying the initial risk assessment and actively participating in it (27.5%); Developing and verifying the evacuation and emergency plans and transmitting information to the teams of intervention and first aid (27.5%); Reporting to the work authorities both the serious accidents as the professional diseases (18%); Advising the executive offices on the correct management of workers’ health (18%); Developing protocols of action on violence in the workplace (9%); Developing working tools for collaboration with the technical department concerning the identification of risks (9%); Using and adapting the specific protocols of health surveillance to nursing taxonomies (9%). Discussion Interventions made by occupational health nurses play an important role in the process of care to workers however, in the current context that recommends a comprehensive and holistic care, these interventions should be planned, implemented and evaluated. The indications of the NIPE project for the validation of a nursing intervention using the Fehring method associated with the Delphi method have been widely applied in validation studies.(3) However, following the criteria proposed by these methods to define the sample of experts in the field of occupational health with knowledge and mastery of the language of nurses/nursing process(3) is a limiting factor, considering there is still a gap in the practical applicability of this international nursing language in the context of occupational health. The Sánchez-Ayllón F, Oliveira AC, Morales I, Sá JD, Pérez PE standardization of these actions through a rating systems facilitates the communication of care.(5) We understand that the content validation by experts in an NIC intervention provides its improvement, as well as the indication of new needs in the area. The judgment of experts regarding the NIC as ‘control and manipulation of the environment in the workplace to promote safety and health of workers’(1) makes us believe and understand the relevance of environmental health, emerging as a relatively new terminology, covering factors between the health/disease process determined by environmental aspects,(6) besides referring to the theory and practice of assessment and control of environmental factors that may affect the health of individuals.(7) It is a dialectical relationship between theory and practice, involving life and work, where there is still a gap for this integration.(8,9) Experts have pointed out almost hegemonically, that there is a need for use and practical applicability of valid interventions, and with level of reliability in a classification system that is specific of the occupational health nursing. The understanding of the need for an environmental control by nursing may be related to the representativeness of this term from the perspective of occupational health. A study indicated the importance of occupational health for the maintenance of environmental health, presenting a retrospective of the main focuses of actions regarding environmental management for health promotion and it was found that in the majority, occupational health was seen as improvement in the quality of work environment, which indicates the need for environmental management to promote worker safety. By observing the activities that stood out, it was found, for example, setting in motion investigation programs and programs to promote health in the workplace in relation to assessment of health risks, reinforcing the important role of health education in occupational health,(6) where there is a need to educate workers in a language with representativeness of standardized nursing activities, indicating its actual application in clinical practice for occupational nursing. A study demonstrated that the application of the nursing process in occupational health provides a systematic care to workers, which allows, through standardization of language, useful interventions towards a positive result, especially in the prevention of risks to this population.(5,7) In face of the work diversity of nurses in occupational health, the additions of activities not contained in the NIC made by the experts as intervention activities are relevant. This emphasizes the real need of these activities to obtain the desired care, since the experts were asked to freely describe actions they deemed relevant, such as identifying and protecting especially sensitive workers and carrying out health surveillance in accordance with the protocols of health monitoring of the ministry for each job position. Occupational health nurses have on their hands the possibility not only of identifying risks, but also of complying with legislation that promotes environmental control and safety.(10) The investigated and reported activities characterize the work of nurses in the context of occupational health, with individual interventions, but mostly collective, which are very important to achieve positive results with regard to the control of the work environment in face of occupational risks, where nurses can promote a secure environment.(11) Although all activities were considered clear by at least 50% of the experts, there is still no consensus as to the clarity of the description of activities. In order to obtain an effective nursing intervention to the population in question, from a standard and evidence-based language, it is necessary a reliable interpretation of the data obtained in the evaluation of the client, from the use of nursing diagnoses. However, the relevant need for further studies of this intervention stands out, including other populations with indications for a clearer writing of the definition and activities, in addition to a better match between the title of the intervention and its definition, in order that these criteria obtain a higher score by experts in the field. And especially studies that prove the real need for adding new activities to the taxonomy, reaching an intervention of quality that faithfully represents nurses’ actions regarding the environmental control to promote safety for the worker. Acta Paul Enferm. 2014; 27(2):173-8. 177 Content validation of the nursing intervention called Environmental Control: worker safety Conclusion References The experts considered the nursing intervention of NIC called Environmental Control: patient safety as a valid intervention for occupational health. The main activities listed as interventions to obtain environmental control for the safety of workers were the following: Determining the physical status of employees for working; Identifying the risks and stressors in the work environment (physical, biological, chemical and ergonomic); Starting the environmental modification to eliminate or minimize risks; Informing workers about the substances to which they may be exposed; Setting investigation programs in motion in the workplace for the early detection of injuries and non-professional illnesses, and setting programs in motion to promote health in the workplace in relation to the assessment of health risks. 1. World Health Organization. Global Strategy on Occupational Health for All. The Way to Health at Work. Recommendation of the Second Meeting of the WHO Collaborating Centres in Occupational Health 114 October 1994. Beijing: China; 1994. [cited 2013 May 8]. Available from: http://www.who.int/occupational_health/en/oehstrategy.pdf. Collaborations Sánchez-Ayllón F contributed in idealization and project design, study execution, analysis and interpretation of data, drafting the article and final approval of the version to be published. Oliveira ACS; Morales I and Sá JD collaborated with the execution of the research, writing the article and final approval of the version to be published. Pérez PE contributed critical review of the relevant intellectual content and approved the final version to be published. 178 Acta Paul Enferm. 2014; 27(2):173-8. 2. Ministerio de la Salud, Servicios Sociales e Igualdad Español [Internet].España: Madrid Protocolos de vigilancia específica a los trabajadores. [citado 2013 May 15]. Available from: http:// www.msc.es/ciudadanos/saludAmbLaboral/saludLaboral/ vigiTrabajadores/protocolos.htm. 3. Fehring RJ. Methods to validate nursing diagnoses. Heart Lung. 1987;16(6):625-9. 4. Consejo General de Enfermería. España: Madrid. Instituto de Salud Carlos III. División de Normalización. 2013. 5. De Cordova PB, Lucero RJ, Jun S. Using the Nursing Interventions Classification as a Potential Measure of Nurse Workload. J Nurs Care Qual. 2010; 25(1):39-45. 6. Fernández Ospina E, Tenjo AM, Uribe Rodríguez M. Identificación de factores psicosociales de riesgo en una empresa de producción. Diversitas. 2009;5(1):161-75. 7. Ball K, Timperio A, Salmon J, Giles-Corti B, Roberts R, Crawford D. Personal, social and environmental determinants of educational inequalities in walking: a multilevel study. J Epidemiol Community Health. 2007;61(2):108-14. 8. Dias EC, Rigotto RM, Augusto LG, Cancio J, Hoefel MG. A saúde ambiental e saúde do trabalhador na atenção primária à saúde, no SUS: oportunidades e desafíos. Ciência & Saúde Coletiva. 2009;14(6):2061-70. 9. París E, Bettini M, Molina H, Mieres JJ, Bravo V, Ríos JC. La importancia de la salud ambiental y el alcance de las unidades de pediatría ambiental. Revista Méd Chile 2009;137(1):101-5. 10. Ward JA, Castro AB, Tsai JH, Linker D, Hildahl L, Miller ME. An injury prevention strategy for teen restaurant workers: Washington state’s ProSafety project. AAOHN J. 2010;58(2):57-7. 11.Castro AB, Sousa JTC, Santos AA. Atribuições do enfermeiro do trabalho na prevenção de riscos ocupacionais. J Health Sci Inst. 2010;28(1):5-7. Original Article Oncoaudit: development and evaluation of an application for nurse auditors Oncoaudit: desenvolvimento e avaliação de aplicativo para enfermeiros auditores Luciane Mandia Grossi1 Ivan Torres Pisa2 Heimar de Fátima Marin1 Keywords Nursing audit; Nursing informatics; Mobile applications; Medical informatics; Pharmaceutical preparations Descritores Auditoria de enfermagem; Informática em enfermagem; Aplicativos móveis; Informática em saúde; Preparações farmacêuticas Submitted March 7, 2014 Accepted March 18, 2014 Corresponding author Heimar de Fatima Marin Napoleão de Barros street, 754, São Paulo, SP, Brazil. Zip Code: 04024-002 [email protected] DOI http://dx.doi.org/10.1590/19820194201400031 Abstract Objective: To develop a web and mobile device application to search for chemotherapy drugs to support nursing audits of hospital bills and to evaluate user satisfaction and tool usability. Methods: Research of technological production for development of an application for web and mobile technology. The product was evaluated by nurse auditors using the System Usability Scale questionnaire. It was also evalutated by health informactics professionals using Nielsen’s heuristics. Results: The application is available at http://telemedicina6.unifesp.br/projeto/oncoaudit. The mobile version can be is accessed at http://play.google.com/intl/pt-BR/about/index.html. Nurse evalaution indicated that the web and mobile versions addressed user needs. In the usability evaluation, 14 problems were identified in the mobile version and eight in the web system. Implementation of improvements according to the evaluation findings were made in both versions. Conclusion: The methods for development and evaluation were adequate to achieve the proposed objective. Resumo Objetivo: Desenvolver aplicativo de consulta de medicamentos quimioterápicos para sistema web e dispositivo móvel para auxiliar na auditoria em enfermagem de contas hospitalares e avaliar quanto a satisfação do usuário e usabilidade. Métodos: Pesquisa de produção tecnológica contendo desenvolvimento de aplicativo web e para tecnologia móvel. O produto foi avaliado quanto à satisfação por enfermeiros auditores utilizando o questionário System Usability Scale (SUS) e quanto à usabilidade pelas heurísticas de Nielsen, por profissionais de informática em saúde. Resultados: O aplicativo esta disponível no http://telemedicina6.unifesp.br/projeto/oncoaudit. O aplicativo móvel pode ser acessado em http://play.google.com/intl/pt-BR/about/index.html. A avaliação pelos enfermeiros indicou que o aplicativo web e móvel estão de acordo com as necessidades dos usuários. Na avaliação de usabilidade foram identificados 14 problemas no aplicativo móvel e oito no sistema web, gerando modificações am ambos. Conclusão: Os métodos escolhidos para desenvolvimento e avaliação mostraram-se satisfatórios para atingir os objetivos propostos. Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil. Universidade Federal de São Paulo, São Paulo, SP, Brazil. Conflicts of interest: none to report. 1 2 Acta Paul Enferm. 2014; 27(2):179-85. 179 Oncoaudit: development and evaluation of an application for nurse auditors 180 Introduction Methods The growth of the supplemental health segment and the widening of care covered by the National Regulatory Agency for Private Health Insurance and Plans (ANS) led health insurances companies to develop strategies to reduce costs. In this scenario, nurses faced a new area of responsibility: serving as account auditors to verify the correspondence between care delivery and amount of transferred funds. Auditing was introduced in the United States in 1918 to verify the quality of obstetric care, followed by other health sectors. Audits can be classified as (a) audits of structure, which monitor the structure or location of care; (b) audits of process, which measure how care is delivered; and (c) audits of results, which provide indicators of care quality. Audits occur retrospectively, i.e. after hospital discharge or simultaneously, while care is being delivered to the patient. In nursing, audits entail the systematic evaluation of the quality of care delivery, verification of compatibility, and evaluation of number of procedures conducted and items in the hospital bill to assure adequate payment. This activity is exclusive of the nurse as stated by resolution no. 266/2001 of Brazilian Federal Nursing Council (COFEN).(1) In a hospital bill audit, the nurse needs to verify whether drugs listed in the bill are consistent with medical prescriptions and if they were charged according to the contracted plan. In practice, pharmaceutical guides are used to verify indication, posology, stability, administration route, and general guidance on the product by the manufacturer. The main references are the Dicionário de Especialidades Farmacêuticas (DEF [pharmaceutical dictionary]) and websites specializing in pharmaceutical guides, such as the Brazilian Health Surveillance Agency (Anvisa) electronic pharmaceutical guides list.(2) Such activity is time consuming and requires completely reading the pharmaceutical guides, and sometimes the access to the Anvisa electronic insert list depends on the available technology, the subscription to the electronic list, and assurance that information is complete and updated. This study is a development applied research of an application for web and mobile technology used to search chemotherapeutic drugs in hospital bill auditing. Software development was based on system development life cycle using the prototyping concept. The phases were (a) communication, which consisted of searching the requisites for the software; (b) planning, which entailed describing the resources that would be used and the schedule to be followed; (c) designing, comprising the model to be executed in agreement with the requisites identified; (d) construction, which combined code generation and tests to reveal errors; and (e) implementation, during which the product was analyzed and assessed. To develop the web environment it was used Drupal, a content management system. Information on each drug were added to a database created by MySQL, a database management system.(3) The mobile application was developed for the Android plataform.(4) This platform was chosen because of the ease of the Java library available via Google (the Accessory Development Kit). One of the predetermind parameters was the use of free software to avoid costs that could interfere in construction of the system. The interface was based on widely used models of eletronic pharmaceutical guides (already mentioned in this paper). In addition, it was used other well-known materials, such the Brazilian Clinical Oncology Manual and Epocrates.(5,6) Javascript technology was applied for its feasibility, portability, easiness of use, safety, scalability, and capacity for creation of components compatible to web enviroment; this enabled the use of different platforms, such as Windows, Linux, and Unix. To address the second objective of this study, the application was evaluated in two stages by two different groups: nurse auditors and health informatics professionals. The nurse auditors met the following inclusion criteria: at least 5 years of experience as a nurse auditor and experience in audit bills at oncology centers. Health informatics profes- Acta Paul Enferm. 2014; 27(2):179-85. Grossi LM, Pisa IT, Marin HF sionals invited had to have, preferably, a specialization, a master’s or doctorate degree in the area, and basic knowledge of Nielsen’s heuristic. To evaluate user satisfaction of nurse auditors, it was applied the System Usability Scale (SUS) questionnaire, which is widely accepted for its trustworthiness and validity.(7) This questionnaire contains a simple scale of ten items, enabling the evaluation of subjective perceptions. A Likert scale was used, with values ranging from 1 (totally disagree) to 5 (total agree); 3 indicated a neutral response. To calculate the SUS score, the contribution score of each item was summed. For items 1, 3, 5, 7, and 9, the score is the position of the scale minus 1; for items 4, 6, 8, and 10, the contribution is 5 discounting the scale position. The total sum of 10 questions, multiplied by 2.5 was used to obtain the global value of system usability. The SUS score ranges from 0 to 100; scores lower than 51 were considered poor, those higher than 71 were good, those higher than 86 were excellent, and those higher than 91 were the best possible scores.(8) This questionnaire has also been applied in other studies, a factor that contributed to be selected.(9) It was decided to use convenience sample where 29 nurse auditors were invited; of these, 10 accepted the invitation and participated in the ealuation. To perform an audit, nurses received a hypothetical case of a hospital bill from an oncology provider. Based on this case, the evaluator had to search in the Oncoaudit system and then complete the SUS questionnaire. In the usability evaluation with health informatics professionals, it was decided to apply Nielsen’s heuristic as the instrument. This method consisted of evaluator analysis of the interface and expression of the evaluator’s option. This instrument has 10 general designed principles called “heuristics”: (1) visibility of system status, (2) match between system and the real world, (3) user control and freedom, (4) consistency and standards, (5) error prevention, (6) recognition rather than recall, (7) flexibility and efficiency of use, (8) aesthetics and minimalist design, (9) helping users recognize, diagnose, and recover from errors, and (10) help support and documentation.(10) First, the application was presented to professionals, and the evaluator inspected the application, using the heuristics as a guide to identify possible problems. The next step was to classify the severity of the problem using a scale from 0 to 4, where 0 = unimportant (did not affect the interface operation); 1 = aesthetic (no immediate need for solution); 2 = simple (low-priority problem that can be corrected); 3 = severe (high-priority problem that must be corrected); and 4 = catastrophic (very severe and must be corrected right away).(11) It was used a routine model to assess Nielsen’s heuristic that has been employed in another Brazilian study.(12) Due to the best cost/benefit ratio that is achieved when three to five individuals conduct an asssement, it was invited three evaluators. Evaluations occured from May to June 2013. Development of this study followed national and international ethical and legal aspects of research on human subjects. Results Drugs selection was based on two pharmaceutical guides and entailed 146 drugs. A total of 30 drugs were excluded because they were duplicates or noncommercialized. After assembly of the final list, pharmaceutical companies and websites were identified. This method enabled us to include more than 68 categories of drugs, yielding 184 drugs to form the database. Oncoaudit was made available at http://telemedicina6.unifesp.br/projeto/oncoaudit/. To access the application, users must first register. After login, the first page lists drugs in alphabetic order. Upon clicking on a drug name, information on that drug appears on a different page organized by topics, as shown in figure 1. The following information was shown for each drug: brand name, generic name, indication, posology, compatiblity with bottles and equiment, stability, diluent, final volume and time of infusion, incompatibility with solutions, route of administration, URL for the pharmaceutical company, references with additional information about the Acta Paul Enferm. 2014; 27(2):179-85. 181 Oncoaudit: development and evaluation of an application for nurse auditors pharmaceutical guide; distributor of the drug, pharmacologic group, pharmaceutical guide in PDF format, and date of registration and updating data. It is important to mention that of 184 drugs, nine were not included in table format because of the length of the text. In such cases, it was opted to include the information “see full prescribing information”. The mobile application uses the MySQL database manager, and is update by synchronization from the web system. The objective of this mobile application was to offer an interface for searching for, but not registering, data. Since all data were available through the web service, all communication of the application with data is done from web services, including login, information on drugs, synchronization, and archives of pharmaceutical guide. Web services were implemented directly in the web system using a plugin by Drupal. The application stored all information of the pharmaceutical guide, including PDFs, in order to enable use even when the mobile device was not connected to the Internet. Data are updated automatically when synchronization was last performed 7 days previously or manually with use of an icon available on the application’s homepage. However, it is necessary to stay connected to the Internet upon first access to perform the initial synchronization with data for the drug pharmaceutical guide and storage data of local login. Synchronization after login ensures the use of as little space as possible in the memory of the device; as a result less time is Figure 1. Display of selected drug, organized by topic 182 Acta Paul Enferm. 2014; 27(2):179-85. needed for downloads. In addition, it also enables users to access the application even if they are not connected in the Internet. To access Oncoaudit on a mobile device (Figure 2), the user must first register in the web system through the link “click here”. In this way, the user will know the web system and the account information will be stored. The four icons developed have the following functions: (1) “look for updates”, used to update the database manually, when new drugs are added in the website; (2) “contact”, used to ask questions, request information, and provide suggestions; (3) “about”, describing the application, its objective, and information about its authors; and (4) “drugs list”, providing access to the complete drug database. Five nurse auditors evaluated the mobile application, and the other five nurses evaluated the web system. Evaluation with the SUS questionnaire showed that the average SUS score was 90 ± 5 for the mobile application and 97 ± 5 for the web system. Nurses considered the mobile application easy to use, useful, innovative, and complete and felt that it provided important information to help them audit bills that referred to antineoplastic drugs. One of the nurses praised the topics’ “stability”, “pharmacological group”, and “compability with bottles and equipment” considering the importance in practice. They also stated that the web system was easy to use and found that information provided is necessary for practice, allowed them to optimize reading of pharmaceutical guide as well trustable. They also suggested that other drugs should be included and the application should be used not only by auditors but also as an instrument for teaching and updating. The three health informatics professionals assessed usability in both the mobile and web environments. Considering total evaluation in both products, they found 14 problems in the mobile version according to Nielsen’s heuristic, whereas the web version showed eight problems. In both versions, only two things were considered catastrophic; two problems were considered severe in web system and four in the mobile version. Grossi LM, Pisa IT, Marin HF perceived that two search filters — brand name and generic name — were unnecessary; the suggestion solution was to include a single filter to find this information. In the nurses’ evaluation, the nurses also suggested including a single filter to find brand name and generic names. Discussion Figure 2. Homepage and page with links available in the mobile device The problem for the mobile version that was classified as catastrophic was comprised in the first heuristic: visiblity of system status. The first evaluator observed a delay of the mobile version’s database with the web system for synchronization of updates. The other evaluator also perceived the same problem but classified the problem as severe. The third evaluator identified another problem that was classified as severe in the heuristic principle “flexibility and efficiency of use” because when the user search for the drug in the specific field, the application did not find those with accent marks. Thus, the evaluator suggested that words with accent marks not be differentiated from words without accent marks. In evaluation of the Oncoaudit in the web system, only one problem was classified as catastrophic and two as severe. The catastrophic problem concerned error prevention, in which the first evaluator verified that in pharmacological group locking could occur during the search. The two severe problems were related to the heuristic principle “flexibility and efficiency of use” in which two evaluators Computers were introduced to nursing professionals more than 40 years ago, and they have been used in decision making systems, guidance of patient care, teaching and training, registration of nursing processes in hospital information systems, and electronic health records. In nurse audit practice, although diffusion is restricted, the informatics have been used to codify physician fees, preanalysis of hospital bill by health providers, and analysis of auditing in relation to the electronic health record. Information technology and communication must be used to improve the professional development, decision support, and representation of resources that optimize the care process and evaluation, assuming that those who have adequate and updated information at the point of care are better able to make decisions.(13) The evaluators in this study suggested that the search function should have a single filter to find both brand and generic names. However, a nurse auditor will not always know if the drug is presented with its generic or brand name. We believe that categorizing information according to topic is faster and more intuitive; this was confirmed by results of evaluation conducted by nurse auditors. Still, having correct information on drugs is fundamental. When some information is omitted, doubts can appear that compromise the result of the analysis. After rigorous reading of pharmaceutical guide and inclusion of the content in the topics, we observed that several drugs with the same active principle had divergent information. Such a discrepancy is relevant during auditing practice and brings several conclusions in the process. Nurse auditing in oncology is an area that often causes doubts, and few nurses identify them. The Acta Paul Enferm. 2014; 27(2):179-85. 183 Oncoaudit: development and evaluation of an application for nurse auditors technical knowledge is imperative for releasing or auditing the charging process in oncology. Previous studies observed the uniformity and deficiency in information in pharmaceutical guide lists about the same drug, such as chemical and pharmacological characteristics, indications, contraindications, precautions and advertencies, drug interactions in adverse effects, posology, and overdosage.(14) The standardization of drug information with the same active principle was not completed, but pharmaceutical guide constitute an important information source in Brazil that has been changed several times: between 1946 and 2006 the number of mandatory items increased and the level of description in pharmaceutical guide increased.(15) The evaluation was conducted using the SUS questionnaire, which was satisfactory; this finding agrees with other studies that also applied the same tool, such as evaluation of management software of diabetes based on Internet technology and a web-based tutorial for parents of children with autism,(16) as well as a system of information exchange in primary health care.(17) In an evaluation using Nielsen’s heuristic, it was understood that this tool is a good alternative to test interactive health websites in settings where time and resourses are limited. Suggestions and opinions given by nurses audit and informatics health professionals helped improve the application through their useful and practical evaluations. Technological advances enable nurses to direct their professional destiny and to adapt technology resources based on practice; they also help nurses to see urgent trends in the health area as a challenge and a single opportunity for careers growth. There are new tools, new areas, and new activites demading specialists in any country, and there are many opportunities for those who decide to incorporate technological information into daily practice. With this research and the development of this application, ir was also expect to incentive the interest of nurse auditors in developing studies to improve the technical knowledge in nursing audit in consonance with technology for professional practice. 184 Acta Paul Enferm. 2014; 27(2):179-85. Conclusion It was developed an application containing information to support auditing of drugs in hospital bills. This tool was evaluated with regard to user satisfaction and usability, which helped promote improvements in software before it becomes available to the public. Even with the limited number of evaluators, it was clear that Oncoaudit can be used in practice for drugs audit. This application can make the auditing process faster and complete. In addition, the study results suggest that the application can have high impact if more pharmacological groups are included. Acknowledgements Dr. Marin acknowledge the support provided by CNPq 477394-2011-6 and 301735/20093. We also thank the partial support of the grant 5D43TW007015-08 from Fogarty International Center and the National Library of Drug, National Institutes of Health. Collaborations Grossi LM contributed to the conception of the project, analysis and interpretation of the data and drafting of the manuscript. Pisa IT contributed with analysis and interpretation of the data and critical review to improve the manuscript intellectual content. Marin HF contributed to the conception of the project, analysis and interpreation of the data, reviews and drafting of the manuscript to improve its intellectual content and approval of thi final version for publication. References 1. Cofen: Conselho Federal de Enfermagem. Resolução Cofen-266/2001 [Internet]. 2001 [citado 2013 Jul 13]. Disponível em: http://novo. portalcofen.gov.br/resoluo-cofen-2662001_4303.html. 2. Brasil. Ministério da Saúde. Agência Nacional de Vigilância Sanitária. Bulário Eletrônico [Internet]. Brasília: Anvisa; c 2005-2009 [citado 2013 Jul 13]. Disponível em: http://www.anvisa.gov.br/datavisa/fila_ bula/index.asp. 3. MySQL: The world’s most popular open source database [Internet]. c2013 [cited 2013 May 19]. Available from: http://www.mysql.com. 4. Licenses. Android Open Source [Internet]. [cited 2013 May 19]. Available from: http://source.android.com/source/licenses.html. Grossi LM, Pisa IT, Marin HF 6. Epocrates [Internet]. c2013 [citado 2012 Maio 19]. Disponível em: http://www.epocrates.com. 12.Gonçalves LL. EditWeb: mecanismos de autoria assistida de páginas para ambiente de EAD via web visando usabilidade e acessibilidade. [Internet]. Porto Alegre (RS). Universidade Federal do Rio Grande do Sul; 2004 [citado 2013 Nov 28]. Disponível em:http://www.lume. ufrgs.br/handle/10183/8694 7. Bangor A, Kortum PT, Miller JT. An empirical evaluation of the system usability scale. International J Hum Comput Interact. 2008;24(6):574–594. 13. Marin HF. Sistemas de Informação em saúde: considerações gerais. J Health Inform. 2010;2(1):20-4. 8. Bangor A, Kortum P, Miller J. Determining what individual SUS scores mean: Adding an adjective ratingscale. J Usabil Stud. 2009;4(3):114–23. 14. Gonçalves SA, Melo G, Tokarski MH, Branco AB. Bulas de medicamentos como instrumento de informação técnico-científica. Rev Saúde Pública. 2002; 36(1):33-9. 5. Manual de oncologia do Brasil. MOC 2013 [Internet]. c2012 [citado 2013 Jul 13]. Disponível em: http://mocbrasil.com. 9. Tenorio JM, Sdepanian VL, Pisa IT, Cohrs FM, Marin HF. Desenvolvimento e avaliação de um protocolo eletrônico para atendimento e monitoramento do paciente com doença celíaca. Rev Inform Teór Aplic. 2011;17(2):210-20. 10. Nielsen J. How to Conduct a Heuristic evaluation [Internet]. 1995 [cited 2013 Dec 19]. Available from: www.nngroup.com/articles/how-toconduct-a-heuristic-evaluation. 11. Nielsen J. Severity ratings for usability problems [Internet]. 1995 [cited 2013 Dec 19]. Avaialble from: www.nngroup.com/articles/how-torate-the-severity-of-usability-problems. 15.Caldeira TR, Neves ER, Perini E. Evolução histórica das bulas de medicamentos no Brasil. Cad Saúde Pública. 2008;24(4):737-43. 16.Kobak KA, Stone WL, Wallace E, Warren Z, Swanson A, Robson K. A web-based tutorial for parents of young children with autism: results from a pilot study. Telemed J E Health. 2011;17(10):804-8. 17.Haarbrandt B, Scwartze J, Gusew N, Seidel C, Kleinschmidt T, Haux R. Primary care provider`s acceptance of health information exchange utilizing IHE XDS. Stud Health Technol Inform. 2013;192: 106-8. Acta Paul Enferm. 2014; 27(2):179-85. 185 Original Article Analysis of hemorrhage at vaginal delivery by erythrocyte and hematocrit indices Análise da hemorragia no parto vaginal pelos índices de eritrócitos e hematócrito Maria Cristina Gabrielloni1 Cláudia Junqueira Armellini2 Márcia Barbieri1 Janine Schirmer1 Keywords Hemorrhage; Postpartum hemorrhage; Parturition; Obstetrical nursing; Hematocrit; Erythrocyte indices Descritores Hemorragia; Hemorragia pós-parto; Parto; Enfermagem obstétrica; Hematócrito; Índices de eritrócitos Submitted March 11, 2014 Accepted March 18, 2014 Corresponding author Maria Cristina Gabrielloni Napoleão de Barros street, 754, São Paulo, SP, Brazil. Zip Code: 04024-002 [email protected] DOI http://dx.doi.org/10.1590/19820194201400032 186 Acta Paul Enferm. 2014; 27(2):186-93. Abstract Objective: To analyze hemorrhage at vaginal delivery using hemoglobin and hematocrit indices. Methods: This was a cross-sectional study of 328 vaginal deliveries divided into spontaneous delivery with or without episiotomy and forceps delivery. The sample was randomly stratified by type of vaginal delivery. Data were collected at admission for delivery, hospital discharge and postpartum return visit. Results: There were 122 (37.2%) deliveries without episiotomy, 147 (44.8%) with episiotomy, and 59 (18.0%) with forceps delivery and episiotomy. Hemoglobin values between admission for delivery and discharge ranged from -5.9 g/dl to 0.7 g/dl. Hemoglobin reduction was significantly higher in women having forceps delivery than in those with spontaneous deliveries, with and without episiotomy (p=0.0133 and p<0.0001, respectively). Hemorrhage was greater in the forceps delivery group than in the other groups. Conclusion: The analysis of hemorrhage at vaginal delivery by using hemoglobin and hematocrit indices showed variation among the three types of vaginal delivery studied. There was greater hemorrhage with forceps delivery and less hemorrhage with spontaneous delivery. In women with forceps delivery, postpartum indices were lower than those at hospital admission. Resumo Objetivo: Analisar a hemorragia no parto vaginal através dos índices de eritrócitos e hematócrito. Métodos: Estudo transversal realizado em 328 partos vaginais divididos em: espontâneo, com e sem episiotomia, e parto fórceps. A amostragem foi aleatória estratificada por tipo de parto vaginal. Os dados foram coletados na internação para o parto, na alta hospitalar e no retorno puerperal. Resultados: Foram estudados 122 (37,2%) partos sem episiotomia, 147 (44,8%) com episiotomia e 59 (18,0%) com uso de fórceps e episiotomia. O valor individual de hemoglobina, entre a internação para o parto e a alta hospitalar variou de -5,9 g/dl a 0,7 g/dl.A redução da hemoglobina foi significativamente maior no parto fórceps comparado aos partos espontâneos, com e sem episiotomia, p=0,0133 e p<0,0001, respectivamente. No parto fórceps a hemorragia é maior quando comparada aos outros tipos de parto Conclusão: A análise da hemorragia no parto vaginal através dos índices de eritrócitos e hematócrito evidenciou que há variação nos três tipos de parto vaginal estudados, sendo a hemorragia maior no parto fórceps e menor no parto vaginal espontâneo. No puerpério, nos casos de partos fórceps estes índices mantiveram-se inferiores aos da internação. Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil. Escola de Enfermagem, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil. Conflicts of interest: none reported. 1 2 Gabrielloni MC, Armellini CJ, Barbieri M, Schirmer J Introduction Blood loss during intra- and postpartum can change hematologic conditions of women. For this reason, obstetric researchers have studied bleeding in this setting.(1,2) Causes of postpartum hemorrhage in vaginal delivery can be associated with prior postpartum hemorrhage, induction or conduction of delivery, third period of prolonged delivery, preeclampsia, nulliparity, failure to fetal descent, forceps or vacuum extraction delivery, third or fourth-degree peripheral laceration, retained placenta, macrosomia, vaginal or perineal laceration that requires suture, multiple gestation, and episiotomy.(2,3) Visual estimation is a widely used method to assess blood loss after delivery.(4) Since 1960, reports have shown a discrepancy between blood loss determined by visual examination and by objective techniques at delivery.(5-8) Methods used to assess blood loss include use of calibrated recipients and laboratory techniques to determine plasma volume and red blood cells before and after delivery using radioisotope labels.(8,9) Mean blood loss during vaginal delivery ranges from 197 ml to 505 ml, and it can be influenced by the assessment method.(2) In clinical practice, when blood loss greater than expected is suspected, hematimetric values are applied to determine the management approach. Blood loss during vaginal or cesarean delivery is not determined routinely, nor are hemoglobin and hematocrit values during the postpartum period. A study by the World Health Organization in Asia that evaluated the relationship between types of delivery and maternal and perinatal results reported higher mortality rates with forceps delivery than with vaginal spontaneous delivery (odds ratio, 3.1; 95% confidence interval, 1.5-6.5). Forceps delivery, cesarean delivery with antepartum indication for such delivery, and cesarean delivery with or without intrapartum indication significantly increased the risk of blood transfusion compared with spontaneous delivery.(10) Hemorrhage is the main direct cause of maternal death throughout the world, especially during the postpartum period, with a rate of 25%.(11) In Brazil, analysis that group causes of maternal death showed that hemorrhage was the second most frequent cause of death. Given the potential impact of maternal blood loss due to delivery, this study sought to analyze hemorrhage during vaginal delivery by using hemoglobin and hematocrit indices. Methods This cross-sectional study was conducted in two hospital of the Brazilian public health system in São Paulo, southeast Brazil. The study population was composed of 328 women divided into groups according to type of delivery: spontaneous with episiotomy, spontaneous without episiotomy, and forceps delivery. Inclusion criteria were primiparity, full-term gestational age, one fetus, live fetus in cephalic presentation, and record of at least three prenatal visits without clinical or obstetrics comorbidities. Exclusion criteria were occurrence of third- or fourth-degree perineal laceration, blood transfusion, and presence of comorbidity. The sample was randomly stratified by type of vaginal delivery, considering a 95% confidence interval. The calculated sample size was 308 deliveries, with an error up to 3% in relation to the real results of the population: 144 vaginal delivery with episiotomy, 109 deliveries without episiotomy and 55 forceps deliveries. The dependent variable, hemorrhage, was evaluated by using the erythrocyte indices of hemoglobin and hematocrit values at hospital admission for delivery, discharge, and postpartum return visit. Type of partum, an independent variable, was categorized as spontaneous delivery, with or without episiotomy, and forceps delivery. Control variables were age, formal education level, marital status, occupation, number of prenatal visits and quarter of first prenatal visit, medical prescription for and use of iron supplement in pregnancy and in the postpartum period, gestational age, use of oxytocin during labor and the third period of laActa Paul Enferm. 2014; 27(2):186-93. 187 Analysis of hemorrhage at vaginal delivery by erythrocyte and hematocrit indices bor, presence and type of perineal laceration, and newborn’s birth weight. Data were collected upon admission for delivery, at discharge (36 to 72 hours postpartum), and at the postpartum return visit (15 to 22 days postpartum) using blood samples collected in a tube with EDTA K2 anticoagulant; hemoglobin level and hematocrit at each phase were measured. Hematologic levels were obtained by blood biochemistry analysis with automatic cell counting using a Celm CC530 cell counter and diluter and evaluation of double counting in a Neubauer chamber. The Student t-test was used to assess differences in hematologic profile, and the chi-square test was used to compare several categories, establishing a 95% confidence interval. Data were analyzed by using the statistical software JMP/ SAA, version 8.0.2. Development of this study followed national and international ethical standards for research on human subjects. Results This study included 328 women who underwent vaginal delivery. Of them, 122 (37.2%) did not episiotomy, 147 (44.8%) had episiotomy, and 59 (18.0%) had forceps delivery with episiotomy. Sociodemographic features included a mean maternal age of 21.7 ± 4.9 years (range, 14 to 39 years). In addition, 62.5% of patients were age >19 years, 72.0% had completed high school, 69.5% had a husband, and 64.3% did not work. Women with the three types of delivery were similar with regard to age, formal education level, marital status, and occupation. Mean gestational age was 39 weeks and 4 days (SD±1.0). We recorded six or more prenatal visits regardless of the type of delivery; more than half of the pregnant women began medical visits in the first quarter of the pregnancy. Prescription of iron supplement ranged from 88.1% to 100.0% according to type of delivery; at least ≥61.5 of women using the supplement. 188 Acta Paul Enferm. 2014; 27(2):186-93. Oxytocin was used during delivery by at least 78.7% of women, regardless of the delivery type. An association between oxytocin use during labor and delivery type was seen (p=0.0435). Frequency of oxytocin use was significantly higher in the episiotomy group than in the group with spontaneous delivery and episiotomy (p=0.0299). Most episiotomies were right mediolateral. Perineal laceration occurred in 8.2% and 69.7% of women and was more frequent in the spontaneous delivery without episiotomy group. There was an association between presence of laceration and type of delivery (p=0.0001). Laceration was significantly less frequent in women who had spontaneous delivery with episiotomy than in those with spontaneous delivery without episiotomy and forceps delivery (p=0.0000 and p=0.0000, respectively). First-degree laceration was significantly more frequent in the group with spontaneous delivery without episiotomy than in the group with spontaneous delivery with episiotomy (p=0.0029) and forceps delivery, in which episiotomy is commonly performed, (p=0.000). Second-degree laceration was significantly more common at spontaneous delivery with episiotomy than at spontaneous delivery without episiotomy (p=0.0000) and spontaneous delivery without episiotomy compared with forceps delivery (p=0.000). The use of oxytocin in the third stage of labor was ≥71.3% or greater, regardless of type of delivery. An association between the use of oxytocin during this period and type of delivery was observed (p<0.0001). Oxytocin use was significantly greater in the spontaneous delivery with episiotomy group than in the group with spontaneous delivery group without episiotomy (p=0.0013). Newborn birth weight ranged between 2210 g and 4440 g, and the mean weight was 3.262 ± 396.29 g. This range in women with spontaneous delivery with episiotomy was higher and significant differed compared with the range in the spontaneous delivery without episiotomy group (p=0.0011). An iron supplement was prescribed to all women after delivery and at hospital discharge. About 75% of women reported using the supplement (Table 1). Gabrielloni MC, Armellini CJ, Barbieri M, Schirmer J Table 1. Hemoglobin and hematocrit values Type of delivery p-value** Forceps delivery vs spontaneous delivery without episiotomy Spontaneous delivery with episiotomy vs spontaneous delivery without episiotomy Spontaneous delivery with episiotomy (SD) Spontaneous delivery without episiotomy (SD) Forceps delivery with episiotomy (SD) Forceps delivery vs spontaneous delivery with episiotomy Admission 12.7(0.87) 12.6 (0.90) 13.1 (0.78) 0.0046* 0.0004* 0.3098 Hospital discharge 10.1(1.19) 10.9 (1.27) 10.0 (1.02) 0.5822 <0.0001* <0.0001* Postpartum visit 12.2(0.88) 12.5 (0.90) 12.4 (0.67) 0.1503 0.3957 0.0038* Admission 39.2(2.98) 38.9 (3.14) 40.5 (2.64) 0.0034* 0.0006* 0.4496 Hospital discharge 30.6(3.66) 33.0 (3.90) 30.4 (3.09) 0.7336 <0.0001* <0.0001* Postpartum visit 37.3(3.01) 38.5 (3.03) 37.9 (2.36) 0.1486 0.2261 0.0008* Variable Hemoglobin (g/dl) Hematocrit (%) At admission for delivery, hemoglobin values ranged from 9.9 g/dl to 15.6 g/dl and hematocrit, from 30% to 49%. Three groups of women had the same hematologic measures at admission with regard to the mean of these ranges; however, women who underwent forceps delivery had significantly higher hematologic values. At hospital discharge, hemoglobin and hematocrit ranged from 6 g/dl to 13.9 g/dl and 20% to 43%, respectively. In the same period, mean hemoglobin and hematocrit values in women who had delivery without episiotomy were significantly higher than in those having other types of delivery. At the postpartum return visit, hemoglobin values ranged between 7.9 g/dl and 14.8 g/dl and hematocrit, between 24% and 44%. Mean hematocrit values at the postpartum return visit for the spontaneous delivery without episiotomy group were sig- nificantly higher than for the spontaneous delivery with episiotomy group (Table 2). Hemoglobin values between hospital discharge and admission for delivery ranged from -5.9 g/dl to 0.7 g/dl. Hemoglobin reduction was significantly greater with forceps delivery than with spontaneous deliveries, with or without episiotomy (p=0.0133 and p<0.0001, respectively). This fact suggested that forceps delivery caused greater blood loss. Hemoglobin reduction in the group with spontaneous delivery without episiotomy was significantly lower than in the spontaneous delivery with episiotomy group (p<0.0001). Individual differences in hemoglobin values between the postpartum return visit and hospital discharge ranged from 1.3 g/dl to 5.5 g/dl. Recovery of hemoglobin levels at spontaneous delivery without Table 2. Mean variation and hemoglobin standard deviation Type of delivery p-value** Spontaneous delivery with episiotomy (SD) Spontaneous delivery without episiotomy (SD) Forceps delivery (SD) Forceps vs spontaneous delivery with episiotomy Forceps vs spontaneous delivery without episiotomy Spontaneous delivery with episiotomy vs spontaneous delivery without episiotomy Hospital admission and discharge -2.6 (1.25) -1.8 (1.27) -3.1 (1.24) 0.0133* <0.0001* <0.0001* Postpartum visit and hospital discharge 2.1 (1.08) 1.6 (1.02) 2.3 (0.85) 0.0647 <0.0001* 0.0008* Variable Hemoglobin (g/dl) SD – standard deviation; ** Student’s t-test; * statistically significant difference Acta Paul Enferm. 2014; 27(2):186-93. 189 Analysis of hemorrhage at vaginal delivery by erythrocyte and hematocrit indices Figure 1. Mean hemoglobin values episiotomy was significantly lower between these two phases compared with other types of delivery. However, this level is compatible with the reduction between hospital discharge and admission. The range in the forceps group was greater than in the spontaneous delivery with episiotomy group, but the difference was not significant. In the forceps delivery group, hemorrhage was greater than in the other groups. Hematologic parameters at admission for delivery seemed to influence recovery of these values, almost achieving values seen in the predelivery period (Figure 1). Discussion In healthy women living in developed countries, blood loss up to 1,000 ml can be considered physiologic, not requiring other treatment beside oxytocic drugs. In developing countries, where anemia prevalence is high, volumes of blood loss less than 1,000 ml can change a woman’s vital functions. Risk of death by hemorrhage after delivery increases when anemia is present; therefore, nonanemic women can tolerate blood loss, but in anemic women blood loss can be fatal. Our results showed a variation of hemoglobin and hematocrit values between admission for de- 190 Acta Paul Enferm. 2014; 27(2):186-93. livery and hospital discharge and between hospital discharge and postpartum return visit, for each type of delivery studied. We also observed that spontaneous delivery with episiotomy and forceps delivery caused a greater effect on blood loss, as evidenced by hemoglobin variation. This effect was smaller in women having spontaneous delivery without episiotomy. In our analysis of the effect of spontaneous delivery with episiotomy, we found significantly greater blood loss than in women with spontaneous delivery without episiotomy. This result is similar to those in other studies that evaluated the use of episiotomy in women who underwent spontaneous vaginal delivery with one fetus and verified that episiotomy was associated with greater blood loss.(12,13) A study carried out in two teaching hospitals in Finland reported that in both primiparous and multiparous women, blood loss between 500 and 1,000 ml occurred more often in the delivery with episiotomy group than in the delivery without episiotomy group. This loss was associated with use of incision in multiparous women, with a statistically significant difference (p≤0.001).(14) An investigation conducted in Germany compared two proposals of episiotomy use in primip- Gabrielloni MC, Armellini CJ, Barbieri M, Schirmer J arous women who underwent spontaneous vaginal delivery and vacuum extraction delivery: (1) restricted use (only for fetal indication) and (2) liberal use (both fetal indication and eminent perineal laceration); the study found no difference in hemoglobin variation between the pre and postpartum periods between women managed according to either of the two proposals.(15) Episiotomy and perineal trauma repair are the two surgical procedures most conducted by obstetricians. In Brazil the episiotomy rate is 71.6%, although current efforts aim to reduce it to 10%. Another study revealed higher hematocrit variation in forceps delivery versus spontaneous delivery: 7.9% ± 5.10% and 4.3% ± .78%, respectively; those results confirm our findings.(16) A retrospective study in Finland showed that mean blood loss in women undergoing forceps delivery was 418 ± 248 ml, evaluated by a combination of direct mean volume of blood and gravimetric technique.(17) The loss was similar to the 405.6 ml found by using the colorimetric technique of hemoglobin dilution. That study also reported that blood loss during delivery without episiotomy was lower than during delivery with episiotomy: volumes of 196.5 ml and 327.0 ml, respectively.(18) Our study found that blood loss was significantly greater with forceps delivery than with spontaneous deliveries with and without episiotomy; a result that agrees with other studies.(16) A study in India compared blood loss among women who had spontaneous deliveries using vacuum extraction or forceps by use of hemoglobin variation measured between pre- and postpartum periods; the researchers reported that the mean blood loss estimated in women who underwent vacuum extraction was less than in women who underwent forceps delivery (234 vs 337 ml; p<0.05). However, mean decrease in hemoglobin at admission and the day after delivery was not statistically significantly different between the two groups (vacuum extraction, 0.86 mg/dl; forceps, 1.02 mg/dl).(2) Therefore, the studies previously mentioned confirm the evidence that spontaneous delivery with episiotomy and forceps delivery causes greater bleeding. An exception is a study by U.S. researchers that reported greater blood loss in women having forceps delivery than in those having spontaneous delivery, but no statistically significant difference was found.(19) A randomized pilot study with full-term pregnant women and a single and cephalic fetus compared two proposals for episiotomy in women undergoing instrumental vaginal delivery with vacuum extraction and forceps. One proposal involved routine use of episiotomy for all deliveries and the other involved restricted use only for imminent laceration. These authors did not observe an association between anal sphincter laceration and the proposal for episiotomy use at forceps delivery. However, the study found an increase in hemorrhage after delivery when episiotomy was routinely used at forceps delivery (odds ratio, 1.75; 95% confidence interval, 0.84 to 3.62).(20) In our study, laceration was frequent at spontaneous delivery without episiotomy and at forceps delivery, but the difference was not significant. First-degree laceration was significantly more frequent in the spontaneous delivery without episiotomy group. Incidence of second-degree laceration was higher in women undergoing spontaneous delivery with episiotomy and those having forceps delivery, but without a statistical difference. A study conducted in Finland showed that in pregnant women, perineal lacerations and other traumas are associated with episiotomy.(14) In addition, authors also reported that first- and second-degree perineal lacerations and vaginal traumas of the labia minor and urethra occur more frequently without episiotomy both in primiparous and multiparous women. The use of episiotomy associated with second-degree laceration is questioned because it can be related to reduced hematimetric values in the postpartum period. Some authors verified that hematocrit reduction at delivery with second-degree laceration compared with delivery with midline episiotomy, and also that more extensive vaginal laceration presented greater hematocrit reduction.(16) Considering the effects of delivery type on blood loss and perineal laceration, the importance of measurement of blood loss is evident. Health care professionals must consider the hematimetric parameters of Acta Paul Enferm. 2014; 27(2):186-93. 191 Analysis of hemorrhage at vaginal delivery by erythrocyte and hematocrit indices women before delivery. If hemoglobin and hematocrit parameters at 26 to 28 weeks of gestation are within normal ranges, measurement of these variables can be avoided during hospital stay for delivery care.(21) This study showed that at the postpartum return visit, hemoglobin and hematocrit indices increased in relation to hospital discharge values without reaching the mean values seen at admission. The indices at the postpartum return visit were significantly higher in women undergoing spontaneous delivery without episiotomy than at delivery with episiotomy. It is important to emphasize that assessment of blood loss is a crucial part of delivery care. This assessment is as important as other technical care procedures provided to women. Conclusion Hemorrhage analysis at vaginal delivery by hemoglobin and hematocrit indices varied among the three types of vaginal delivery assessed. Hemorrhage was greater with forceps delivery and lower with spontaneous vaginal delivery. In cases of forceps delivery, indices during the postpartum period were lower than those observed during hospital stay. Acknowledgment This study was supported by the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), process n° 2007/04350-5. Collaborations Gabrielloni MC; Armellini CJ; Barbieri M and Schirmer J contributed to the conception of the project, analysis and interpretation of the data, drafting and critical review of the manuscript to improve its intellectual content and approval of the final version to be published. References 1. Kavle JA, Khalfan SS, Stoltzfus RJ, Witter F, Tielsch JM, Caulfield LE. Measurement of blood loss at childbirth and postpartum. Int J Gynaecol Obstet. 2006;95(1):24-8. 192 Acta Paul Enferm. 2014; 27(2):186-93. 2. Shashank S, Neena R, Singh JR. A prospective randomized study comparing maternal and fetal effects of forceps delivery and vacuum extraction. J Obstet Gynaecol India. 2013;63(2):116-9. 3. Sosa CG, Althabe F, Belizán JM, Buekens P. Risk factors for postpartum hemorrhage in vaginal deliveries in a Latin-American population. Obstet Gynecol. 2009;113(6):1313-9. 4. Dildy GA, Paine AR, George NC, Velasco C. Estimating blood loss: can teaching significantly improve visual estimation? Obstet Gynecol. 2004;104(3):601-6. 5. Brant HA. Precise estimation of postpartum haemorrhage: difficulties and importance. Br Med J. 1967;1(5537):398-400. 6 Duthie SJ, Ven D, Yung GL, Guang DZ, Chan SY Ma HK. Discrepancy between laboratory determination and visual estimation of blood loss during normal delivery. Eur J Obstet Gynecol Reprod Biol. 1991;38(2):119-24. 7. Larsson C, Saltvedt S, Wiklund I, Pahlen S, Andolf E. Estimation of blood loss after cesarean section and vaginal delivery has low validity with a tendency to exaggeration. Acta Obstet Gynecol Scand. 2006; 85(2):1448-52. 8. Stafford I, Dildy GA, Clark SL, Belfort MA. Visually estimated and calculated blood loss in vaginal and cesarean delivery. Am J Obstet Gynecol. 2008;199(5):519. e1-7. 9. de Jonge A, van Diem MT, Scheepers PL, van der Pal-de Bruin KM, Lagro-Janssen AL. Increased blood loss in upright birthing positions originates from perineal damage. BJOG. 2007;114(3):349-55. 10.Lumbiganon P, Laopaiboon M, Gülmezoglu AM, Souza JP, Taneepanichskul S, Ruyan P, et al.World Health Organization Global Survey on Maternal and Perinatal Health Research Group. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007-08. Lancet. 2010;375(9713):490-9. 11.World Health Organization. WHO guidelines for the management of postpartum haemorrhage and retained placenta. Geneva: World Health Organization; 2009. 12.Lam KW, Wong HS, Pun TC. The practice of episiotomy in public hospitals in Hong Kong. Hong Kong Med J. 2006;12(2):94-8. 13. Husic A, Hammoud MM. Indications for the use of episiotomy in Qatar. Int J Gynaecol Obstet. 2009;104(3):240-1. 14.Räisänen S, Vehviläinen-Julkunen K, Heinonen S. Need for and consequences of episiotomy in vaginal birth: a critical approach. Midwifery. 2008;26(3):348-56. 15.Dannecker C, Hillemanns P, Strauss A, Hasbargen U, Hepp H, Anthuber C. Episiotomy and perineal tears presumed to be imminent: randomized controlled trial. Acta Obstet Gynecol Scand. 2004;83(4):364-8. 16. Ries LT, Kopelman JN, Macri CI. Evaluation of routine antepartum and postpartum blood counts. J Reprod Med. 1998;43(7):581-5. 17.Gardberg M, Ahinko-Hakamaa K, Laakkonen E, Kivelä P. Use of obstetric forceps in Finland today--experience at Vaasa Central Hospital 1984-1998. Acta Obstet Gynecol Scand. 1999;78(9):803-5. 18.Wallace G. Blood loss in obstetrics using a haemoglobin dilution technique. J Obstet Gynaecol Br Commonw. 1967;74(1):64-7. 19.Yancey MK, Herpolsheimer A, Jordan GD, Benson WL, Brady K. Maternal and neonatal effects of outlet forceps delivery compared with spontaneous vaginal delivery in term pregnancies. Obstet Gabrielloni MC, Armellini CJ, Barbieri M, Schirmer J Gynecol. 1991;78(4):646-50. 20.Murphy DJ, Macleod M, Bahl R, Goyder K, Howarth L, Strachan B. A randomized controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study. BJOG. 2008;115(13):1695-702. 21.Sherard GB, Newton ER. Is routine hemoglobin and hematocrit testing on admission to labor and delivery needed? Obstet Gynecol. 2001;98(6):1038-40. Acta Paul Enferm. 2014; 27(2):186-93. 193