APE 27(2) ingles.indb

Transcription

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/
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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
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
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
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
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)
97
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
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.
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
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
“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.
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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
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.
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
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.
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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)
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
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
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.
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.
1
DOI
http://dx.doi.org/10.1590/19820194201400020
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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
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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
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
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-
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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
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.
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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
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
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.
1
2
Acta Paul Enferm. 2014; 27(2):115-9.
115
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
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
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
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
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.
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
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)
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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.
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.
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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
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Daytime napping and mortality, with a special reference to cardiovascular
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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
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in older women: the study of osteoporotic fractures. J Am Geriatr Soc.
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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.
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
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
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)
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].
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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
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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.
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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.
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Alexandre DT, Vieira ML. [Attachment relationships among
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institutionalized children living in a shelter situation]. Psicol Estudo.
2004;9(2):207-17. Portuguese.
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USP. 2010;44(2):517-22. Portuguese.
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childhood to family relationships: some theoretical questions]. Psicol
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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
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.
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
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
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.
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.
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
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.
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.
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.
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
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
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%).
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
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
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.
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3. Tudela P, Lacoma A, Prat C, Mòdol JM, Giménez M, Barallat J.
Predicción de bacteriemia en los pacientes con sospecha de infección
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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.
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al. Reducing blood culture contamination by a simple informational
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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.
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.
1
Acta Paul Enferm. 2014; 27(2):151-6.
151
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.
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
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
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
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.
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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
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.
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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
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
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.
1
2
Acta Paul Enferm. 2014; 27(2):157-64.
157
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)
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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
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
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(%)
5(31.25)
8(50)
2(12.5)
1(6.25)
0(0)
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)
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(%)
0(0)
0(0)
5(31.25)
7(43.75)
4(25)
0(0)
0(0)
1(6.25)
4(25)
11(68.75)
0(0)
2(12.5)
10(62.5)
2(12.5)
2(12.5)
After
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)
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)
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)
0(0)
0(0)
0(0)
11(68.75)
5(31.25)
0(0)
0(0)
0(0)
8(50)
8(50)
Variables
Before surgery
Mobility
Satisfaction in relation to sleep
Self-satisfaction
Satisfaction with the conditions of the place of residence
After surgery
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
Table 3. Evaluation of patient satisfaction before and after bariatric surgery
Percentage of satisfaction in surgery
Variables
p-value
Before
%
After
%
37.50
100.00
0.01
37.50
100.00
0.01
50.00
81.25
0.02
31.25
62.50
0.08
Enjoyment of life
25.00
93.75
0.01
Meaning of life
50.00
100.00
0.01
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
6.25
68.75
0.04
18.75
93.75
0.03
6.25
25.00
0.08
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
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
31.25
81.25
0.01
75.00
100.00
0.08
75.00
87.50
0.58
81.25
99.25
0.16
68.75
100.00
0.04
43.75
31.25
0.10
Mobility
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
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
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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
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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
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Itapevi: AC Farmacêutica; 2009.
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CM. Percepção do adolescente obeso sobre as repercussões da
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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
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)
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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
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
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).
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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).
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
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,
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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)
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.
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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
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.
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.
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
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
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.
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Carlos III. División de Normalización. 2013.
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Classification as a Potential Measure of Nurse Workload. J Nurs Care
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Diversitas. 2009;5(1):161-75.
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social and environmental determinants of educational inequalities in walking:
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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.
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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.
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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
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.
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
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
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.
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
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.
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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
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 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).
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
without episiotomy
Spontaneous delivery
with episiotomy
vs
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
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-
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
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
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