Staphylococcus sp

Transcription

Staphylococcus sp

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(3), May/June 2014
ISSN: 1982-0194 (electronic version)
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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
Ana Lucia de Moraes Horta, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Ariane Ferreira Machado Avelar, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Bartira de Aguiar Roza, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Elena Bohomol, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Elisabeth Niglio de Figueiredo, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Erika de Sá Vieira Abuchaim, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Maria Magda Ferreira Gomes Balieiro, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Rosely Erlach Goldman, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Tracy Heather Herdman, University of Wisconsin, CEO & Executive Director NANDA International, Green Bay-Wisconsin, USA
Editorial Board
National
Alacoque Lorenzini Erdmann, Universidade Federal de Santa Catarina-UFSC, Florianópolis-SC, Brazil
Ana Cristina Freitas de Vilhena Abrão, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Cibele Andrucioli de Matos Pimenta, Escola de Enfermagem da Universidade de São Paulo-EE/USP, São Paulo-SP, Brazil
Circéa Amália Ribeiro, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Conceição Vieira da Silva-Ohara, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Elucir Gir, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Emília Campos de Carvalho, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Isabel Amélia Costa Mendes, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Isabel Cristina Kowal Olm Cunha, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Ivone Evangelista Cabral, Escola de Enfermagem Anna Nery- EEAN/UFRJ, Rio de Janeiro-RJ, Brazil
Janine Schirmer, Universidade Federal de São Paulo-USP, São Paulo-SP, Brazil
Josete Luzia Leite, Escola de Enfermagem Anna Nery - EEAN/UFRJ, Rio de Janeiro-RJ, Brazil
Lorita Marlena Freitag Pagliuca, Universidade Federal do Ceará-UFC, Fortaleza-CE, Brazil
Lúcia Hisako Takase Gonçalves, Universidade Federal de Santa Catarina-UFSC, Florianópolis-SC, Brazil
Margareth Ângelo, Universidade de São Paulo-USP, São Paulo-SP, Brazil
Margarita Antônia Villar Luís, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Maria Antonieta Rubio Tyrrel, Escola de Enfermagem Anna Nery- EEAN/UFRJ, Rio de Janeiro-RJ, Brazil
Maria Gaby Rivero Gutiérrez, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Maria Helena Costa Amorim, Universidade Federal do Espírito Santo-UFES, Vitória-ES, Brazil
Maria Helena Lenardt, Universidade Federal do Paraná-UFP, Curitiba-PR, Brazil
Maria Helena Palucci Marziale, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Maria Júlia Paes da Silva, Universidade de São Paulo-USP, São Paulo-SP, Brazil
Maria Márcia Bachion, Universidade Federal de Goiás-UFG, Goiânia-GO, Brazil
Maria Miriam Lima da Nóbrega, Universidade Federal da Paraíba-UFPB, João Pessoa-PB, Brazil
Mariana Fernandes de Souza, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
I
Mavilde da Luz Gonçalves Pedreira, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Paulina Kurcgant, Universidade de São Paulo-USP, São Paulo-SP, Brazil
Raquel Rapone Gaidzinski, Universidade de São Paulo-USP, São Paulo-SP, Brazil
Rosalina Aparecida Partezani Rodrigues, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Silvia Helena De Bortoli Cassiani, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Telma Ribeiro Garcia, Universidade Federal da Paraíba-UFPB, João Pessoa-PB, Brazil
Valéria Lerch Garcia, Universidade Federal do Rio Grande-UFRGS, Rio Grande-RS, Brazil
International
Barbara Bates, University of Pennsylvania School of Nursing - Philadelphia, Pennsylvania, USA
Donna K. Hathaway, The University of Tennessee Health Science Center College of Nursing; Memphis, Tennessee, USA
Dorothy A. Jones, Boston College, Chestnut Hill, MA, USA
Ester Christine Gallegos-Cabriales, Universidad Autónomo de Nuevo León, Monterrey, Mexico
Geraldyne Lyte, University of Manchester, Manchester, United Kingdom, USA
Helen M. Castillo, College of Health and Human Development, California State University, Northbridge, California, USA
Jane Brokel, The University of Iowa, Iowa, USA
Joanne McCloskey Dotcherman, The University of Iowa, Iowa, USA
Kay Avant, University of Texas, Austin, Texas, USA
Luz Angelica Muñoz Gonzales, Universidad Nacional Andrés Bello, Santiago, Chile
Margaret Lunney, Staten Island University, Staten Island, New York, USA
María Consuelo Castrillón Agudelo, Universidad de Antioquia, Medellín, Colombia
Maria Müller Staub, Institute of Nursing, ZHAW University, Winterthur, Switzerland
Martha Curley, Children Hospital Boston, Boston, New York, USA
Patricia Marck, University of Alberta Faculty of Nursing, Edmonton Alberta, Canada
Shigemi Kamitsuru, Shigemi Kamitsuru, Kangolabo, Tokyo, Japan
Sue Ann P. Moorhead, The University of Iowa, Iowa, USA
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III
Editorial
T
ransplantation has celebrated major achievements over the past
decades due to more refined surgical techniques, more potent and
targeted immunosuppressive drugs, and better treatments against
infection. Survival rates after solid organ transplantation have improved
significantly although this has been primarily achieved by a decrease in organ attrition in the first year post-transplant. Improving long-term survival
beyond one year post-transplant remains the major challenge of transplant
clinicians and researchers.
The hight attrition rates in the long-term after transplantation is lead by
existing pre-transplant and newly-developed comorbidities post-transplant,
due to not only the side effects of immunosuppressants but also to unhealthy
life style (e.g., smoking, sedentarism, unhealthy diet). Furthermore, medication non-adherence is associated with increased risk in late acute rejections,
graft loss, and possibly death, besides the disease burden in this population.
In order to improve long-term outcomes after solid organ transplantation,
investment in new models of care, such as the Chronic Care Model (CCM),
has been proposed. The CCM is based on the principles of chronic illness
management (CIM), addressing the needs of solid organ transplant recipients
regarding continuity of care and support for patient self-management. The
CCM contrasts with the prevailing acute care model. Nurses play a crucial
role in CCM, especially in the self-management support and providing continuity of care across institutional boundaries. One Canadian quase-experimental study showed that implementing the CCM in transplant patient’s
follow-up improved clinical and healthcare utilization outcomes.
In order to better understand the practice patterns regarding CIM worldwide in transplantation, the Building research initiative group: chronic illness
management and adherence in transplantation (BRIGHT) study was launched.
This study covers 4 continents, 11 countries and 38 heart transplant centers.
This study will allow describing and benchmarking transplant patient’s health
behaviors as well as practice patterns of CIM in transplantation and provide
transplant clinicians with essential information on how to improve their transplant practices with the goal to improve long-term outcomes post-transplant.
Sabina De Geest
PhD, RN, FAAN, FEANS, FRCN
University of Basel, Switzerland & KU Leuven, Belgium
Lut Berben
PhD, RN
University of Basel, Switzerland & KU Leuven, Belgium
DOI: http://dx.doi.org/10.1590/1982-0194201400033
IV
Contents
Original Articles
Nursing faculty’s opinion on effectiveness of nonverbal communication in the classroom
Opinião de docentes de enfermagem sobre a efetividade da comunicação não verbal durante a aula
Rosely Kalil de Freitas Castro Carrari de Amorim, Maria Júlia Paes da Silva�� 194
Prevalence of common mental disorders in primary health care
Prevalência de transtorno mental comum na atenção primária
Roselma Lucchese, Kamilla de Sousa, Sarah do Prado Bonfin, Ivânia Vera, Fabiana Ribeiro Santana�� 200
Prevalence of depressive symptoms and associated
factors among institutionalized elderly
Prevalência de sintomatologia depressiva e fatores associados entre idosos institucionalizados
Márcia Carréra Campos Leal, João Luis Alves Apóstolo, Aída Maria de Oliveira Cruz Mendes,
Ana Paula de Oliveira Marques�� 208
Ethical conflicts experienced by nurses during the organ donation process
Conflitos éticos vivenciados por enfermeiros no processo de doação de órgãos
Mara Nogueira de Araújo, Maria Cristina Komatsu Braga Massarollo�� 215
Translation, adaptation and validation of a self-care
scale for type 2 diabetes patients using insulin
Tradução, adaptação e validação de uma escala para o autocuidado de portadores de diabetes
mellitus tipo 2 em uso de insulina
Thaís Santos Guerra Stacciarini, Ana Emilia Pace�� 221
Quality of life related to the health of chronic renal failure patients on dialysis
Qualidade de vida relacionada à saúde de pacientes renais crônicos em diálise
Jéssica Maria Lopes, Raiana Lídice Mor Fukushima, Keika Inouye, Sofia Cristina Iost Pavarini, Fabiana de Souza Orlandi��230
Social and clinical factors causing mobility limitations in the elderly
Fatores sociais e clínicos que causam limitação da mobilidade de idosos
Jorge Wilker Bezerra Clares, Maria Célia de Freitas, Cíntia Lira Borges�� 237
Care practices for patient safety in an intensive care unit
Práticas assistenciais para segurança do paciente em unidade de terapia intensiva
Taís Pagliuco Barbosa, Graziella Artuzi Arantes de Oliveira, Mariana Neves de Araujo Lopes,
Nádia Antonia Aparecida Poletti, Lúcia Marinilza Beccaria�� 243
Analysis of blood pressure records at post-anesthesia recovery room
Análise dos registros da pressão arterial na sala de recuperação pós-anestésica
Aline Aparecida Souza Cecílio, Aparecida de Cássia Giani Peniche, Débora Cristina Silva Popov�� 249
Difficulties faced by parents of children with gastroesophageal reflux disease
Dificuldades enfrentadas pelos pais de crianças com doença do refluxo gastroesofágico
Jacqueline Andréia Bernardes Leão Cordeiro, Sacha Martins Gualberto, Virginia Visconde Brasil,
Grazielle Borges de Oliveira, Antonio Márcio Teodoro Cordeiro Silva�� 255
Prevalence of burnout syndrome among resident nurses
Ocorrência da síndrome de Burnout em enfermeiros residentes
Kelly Fernanda Assis Tavares, Norma Valéria Dantas de Oliveira Souza, Lolita Dopico da Silva,
Celia Caldeira Fonseca Kestenberg�� 260
V
Compliance with outpatient clinical treatment of hypertension
Adesão ao tratamento clínico ambulatorial da hipertensão arterial sistêmica
Aurelina Gomes e Martins, Suzel Regina Ribeiro Chavaglia, Rosali Isabel Barduchi Ohl, Igor Monteiro Lima Martins,
Mônica Antar Gamba�� 266
Nasal colonization by Staphylococcus sp. in inpatients
Colonização nasal por Staphylococcus sp. em pacientes internados
Gilmara Celli Maia de Almeida, Nara Grazieli Martins Lima, Marquiony Marques dos Santos,
Maria Celeste Nunes de Melo, Kenio Costa de Lima�� 273
Occurrence of occupational accidents involving potentially
contaminated biological material among nurses
Ocorrência de acidentes de trabalho com material biológico potencialmente contaminado em
enfermeiros
Marília Duarte Valim, Maria Helena Palucci Marziale, Miyeko Hayashida, Miguel Richart-Martínez�� 280
Changes in Quality of Life after kidney transplantation and related factors
Mudanças na qualidade de vida após transplante renal e fatores relacionados
Ana Elza Oliveira de Mendonça, Gilson de Vasconcelos Torres, Marina de Góes Salvetti, Joao Carlos Alchieri,
Isabelle Katherinne Fernandes Costa�� 287
VI
Original Article
Nursing faculty’s opinion on effectiveness of
non-verbal communication in the classroom
Opinião de docentes de enfermagem sobre a efetividade
da comunicação não verbal durante a aula
Rosely Kalil de Freitas Castro Carrari de Amorim1
Maria Júlia Paes da Silva1
Keywords
Communication; Nonverbal
communication; Education, nursing;
Faculty, education; Teaching/methods
Descritores
Comunicação; Comunicação não
verbal; Educação em enfermagem;
Docentes de Enfermagem; Ensino/
métodos
Submitted
March 13, 2014
Accepted
May 26, 2014
Corresponding author
Rosely Kalil de Freitas Castro Carrari de
Amorim
Doutor Enéas de Carvalho Aguiar
Avenue, 419, São Paulo, SP, Brazil.
Zip Code: 05403-000
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400034
194
Acta Paul Enferm. 2014; 27(3):194-9.
Abstract
Objective: To determine the opinion of nursing faculty and a researcher on the effectiveness of non-verbal
communication in the classroom.
Methods: This descriptive study included 11 nursing professors filmed for 220 minutes. Fourteen aspects of
non-verbal communication were evaluated. Opinions about the effectiveness of non-verbal communication are
expressed as simple frequencies.
Results: Professors identified 71.43% of postures (as coherent, good, effective, and adequate), 62.5%
of facial expressions (efficient, positive, and reinforcing/following the speech), 83.33% of voice rhythms
(effective, good, and adequate speed), 61.11% of physical energy levels (good rhythm, active, attentive,
effective, adequate, and alert), and 78.95% of body postures (kept moving, standing, remaining on feet, using
hand movements to illustrate points, attention focused on students, position close to students’ desks). A less
frequent inefficient non-verbal communication was seen among.
Conclusion: Nursing professors’ opinions on non-verbal communication in the classroom were general and
non-specific, indicating inadequate application of non-verbal communication. Professors identified inefficient
non-verbal communication behavior less often than did one of the current researchers.
Resumo
Objetivo: Conhecer a opinião de docentes de enfermagem e da pesquisadora sobre a efetividade da
comunicação não verbal durante as aulas.
Métodos: Estudo descritivo no qual foram incluídos 11 docentes de enfermagem em 220 minutos de filmagem.
Foram avaliados 14 aspectos da comunicação não verbal. A opinião sobre a efetividade da comunicação não
verbal foi apresentada em frequência simples.
Resultados: Os docentes identificaram: 71,43% da postura (coerente, boa, efetiva e adequada); 62,5% das
expressões faciais (eficientes, positivas e reforçando/acompanhando a fala); 83,33% do ritmo da voz (efetivo,
bom e com velocidade adequada); 61,11% do nível de energia − física (ritmo bom, ativo, atento, efetivo,
adequado e alerta); 78,95% da postura corporal (manter-se em movimento, estar ereto, de pé, usar gestos
ilustradores, voltar-se para os alunos, estar próximo dos alunos das carteiras da frente). Além disso, houve
uma menor frequência de comunicação não verbal ineficaz entre os docentes.
Conclusão: A opinião dos docentes de enfermagem sobre a comunicação não verbal durante as aulas é
geral e inespecífica, indicando inadequação na aplicação desta comunicação. Os docentes identificaram
comportamentos comunicativos não verbais ineficazes em menor freqüência do que a pesquisadora.
Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, Brazil.
Conflicts of interest: none to report.
1
Amorim RK, Silva MJ
Introduction
Technologic advances have been gaining prominence everywhere, including the classroom environment. The use of computers, smartphones, and
tablets by students presents undeniable interference. These devices divert students’ attention from
the professor and change the professor-student relationship. This reflects how both professor and students have been interacting in this context.
Study of the professor-student relationship deserves emphasis to establish positive affective ties
that enable productive information and knowledge
exchange in this new reality. To ensure an adequate
relationship, nursing professors should understand
methods of communication, including non-verbal
communication. Communication involves an interpersonal dimension that characterizes relationships
and should be understood to be effectively used.
Educators mention that effective professors
must model behavior and qualities that are in consonance with the lesson taught, be positive and
hopeful, how to listen and talk, and show concern
for students’ well-being. These abilities can be developed, especially through effective non-verbal
communication, which is an instrument to achieve
this result.(1)
Humans differ from other animals by their
ability to perform actions consciously (i.e., to
act intentionally and not by instinct or by conditioned reflex); this is called praxis or work. Work is
also an interventional instrument and a measure of
human appropriation of the world.(2) For this reason, if a professor’s role is to build knowledge for
students through information transmission and
exchange, the professor must communicate appropriately using conscious transformative knowledge
and non-verbal communication. This will provide
the professor the skills to develop an activity that
is in consonance with his or her intentions as a
learning mediator.
There is a schematic chart of non-verbal communication models that can be adapted to the professor-student relationship. This chart shows how
the use of non-verbal is effective in interpersonal
interactions. Non-verbal communicative behavior
is separated into effective/efficacious use and inefficacious use with regard to the following: physical
posture, eye contact, the use of furniture, clothing,
facial expressions, and interpersonal distance. The
behaviors considered effective/efficacious are those
that encourage the other person to talk because he
or she feels accepted and respected; the inefficacious
behaviors are those that weaken the conversation.(3)
Studies on nursing communication that approach the teaching-learning process point out
that the mediator aspect is the importance of
conscience that the professor must have on his/
her communicative role.(4-6)
The difficulty of codifying students’ non-verbal
communication behavior was noted in a study with
nursing faculty that aimed to verify the existence
of differences in professors’ perceptions of students’
feelings before and after an explanatory presentation.(6) The study found that professors’ perceptions
with regard to identifying feelings improved after
the explanation, when their attention was directed
toward non-verbal communication.(6)
Because of the interference of technologic advances and new teaching-learning techniques in the
classroom, studies on interpersonal communication involving professor-student should be redone,
reviewed, and discussed in this new context. This
especially pertains to studies on relative changes in
non-verbal communication, an interpersonal dimension that qualifies the relationships.
This study sought to determine the opinions
of nursing faculty and a researcher’s on the effectiveness of non-verbal communication in the
classroom.
Methods
This descriptive study was carried out at private
university in the city of São Paulo, located in the
southeast region of Brazil. We included 11 nursing
professors who taught in at least two disciplines in
the nursing undergraduate program.
Communication is a dynamic process. For
this reason, we used video recording in the teaching-learning context in the classroom environment.
Acta Paul Enferm. 2014; 27(3):194-9.
195
Nursing faculty’s opinion on effectiveness of non-verbal communication in the classroom
The filming started 30 minutes after the start of class
and lasted for 20 minutes without interruptions.
The camera was placed at medium body frame because most non-verbal communication occurs in
this perspective.
Because filming focused on the professor, the
camera was positioned so that only the professor
was captured. Only the backs of students were
filmed. All students were informed about the
reason of the filming and were told they would
not appear in the video because the focus was
only the professor.
In the second step, a day was scheduled with
each professor to watch the video with the researcher. Before the viewing began, the researcher
explained to the professor how the data collection
instrument was composed and how it must completed. The professor was also told that the he/she
was authorized to see the video twice, if necessary.
On the data collection form professors described
their perceptions after watching the video, pointing out efficient and inefficient examples of the
14 aspects of non-verbal communication assessed
(posture, eye contact, furniture, clothes, facial
expression, mannerism, rhythm and volume of
voice, level of physical energy, interpersonal distance, touch, head movement, body posture, and
paraverbal characteristics).
The researcher also watched each video by herself and completed the instrument. Data collected
from professors and from the researcher were analyzed based on the adopted theoretical reference.
Results were expressed using simple frequencies
of professors who were able to identify the times
they expressed non-verbal signs in the classroom
for each aspect.
Development of this study followed national
and international ethical and legal aspects of research on human subjects.
Results
Eleven nursing faculty were filmed and interviewed.
The participants’ mean time as a professor was 18
years (range, 7 to 29 years).
196
Acta Paul Enferm. 2014; 27(3):194-9.
All professors were filmed in the classroom,
with student desks organized into rows. The
classroom also contained a support table for the
teacher that was placed closed to a white board,
generally on the side opposite the entrance door.
The white board was used to project slides from
a monitor connected to the professor’s personal
computer. Some professors used the white board
to make notes while explaining the subjects addressed during the class. In the institution where
this study was conducted, the use of a white coat
by the professor was optional.
Table 1. Nursing faculty and the researcher’s opinion
Researcher’s opinion
Non-verbal communication
Faculty’s opinion
Effective
use
Inefficient
use
Effective use
Inefficient
use
Posture
14
10
10
3
Eye contact
20
4
11
5
Furniture
12
10
7
7
Clothes
7
8
11
0
Facial expression
16
10
10
3
Mannerism
0*
39
4*
9
Volume of voice
19
3
10
1
Tone of voice
12
10
10
3
Level of energy
18
5
11
1
Personal distance
27
12
9
5
Touch
20
2
6**
3
Head movement
22
2
11
1
Body posture
19
24
15
5
Paraverbal
20
13
10
5
*Os maneirismos não devem existir, portanto, o eficaz é zero de maneirismos, embora quatro docentes
tenham achado seus maneirismos efetivos; ** um docente tocou uma aluna, considerando o toque efetivo;
outros cinco docentes, que não fizeram uso do toque com os alunos, julgaram a ausência do toque efetiva,
por entenderem que o mesmo não caberia naquela situação
Table 1 shows the professors’ and the researcher’s opinions regarding the efficient and inefficient use of non-verbal communication.
During the 20 minutes of filming observed by
the researcher for each non-verbal dimension, the
absolute number of effective or ineffective instances
she perceived computed and considered as 100%.
For example, for posture, there were 14 instances
of effective use and 10 instances of ineffective use
of non-verbal communication, which represent the
sum of the videos of all professors.
The dimensions perceived more by the professors than by researcher concerned the effectiveness of non-verbal signs produced (over 60%) and
how professors described each dimension (noted
in parentheses). Professors identified 71.43% of
Amorim RK, Silva MJ
postures (coherent, good, effective and adequate),
62.5% of facial expressions (efficient, positive and
reinforcing/following the speech), 83.33% of voice
rhythms (effective, good and adequate speed),
61.11% of physical energy levels (good rhythm,
active, attentive, effective, adequate, and alert),
78.95% of body postures (kept moving, standing,
remained on feet, using hand movements to illustrate points, attention focused on students, position close to students’ desks).
All professors considered clothes to be standard and adequate for the classroom, with pleasing and neutral colors; however, the researcher
considered inappropriate that some professors
had their white coat opened. The majority of
professors, 54.5%, did not know the meaning of
the term “mannerism.”
Professors perceived fewer inefficient non-verbal
communication behavior than did the researcher
(Table 1). They did not perceive details that could
harm the professor-student relationship, such as
those found in posture, organization of furniture,
mannerisms, rhythm of voice, interpersonal distance, absence of touch (even in situations where
it seemed appropriate), head movement, body posture, and paraverbal aspects.
Discussion
A limitation of this study was its descriptive design,
which did not permit the researchers to establish
relations of cause and effect, the subjective characteristics of non-verbal communication, the objective of the study, and the comparison between
professors and the researcher.
Our results show the importance of non-verbal
communication in the learning-teaching environment.
Adequate codification of non-verbal communication requires capacitation, training, conscience,
and constant attention during the observation period; several non-verbal sings are transmitted at the
same time as verbalization mainly. These can be
considered microexpressions that last 1/12 to 1/5
seconds and represent, in a non-verbal form, the
speakers’ true feelings.(7)
Most people cannot, without training, perceive
microexpressions during a conversation because
these are mixed with words, tone of voice, and gestures.(7) This difficulty also stems from the fact that
people tend to think beforehand of what they will
say unless they only observe and listen.
We verified that after the initial 5 minutes of adaptations and adjustments, some professors retained
their ineffective communicative behaviors throughout the rest of the filming. Such behaviors included
distance and posture in relation to students, tense
and angry facial expressions, mannerisms, low
voice, accelerated rhythm of voice, keeping a distance from the students, positioning of the head at
variance with voice projection, tense body posture,
and repetitive paraverbal characteristics, with word
repetitions at the end of the discourse.
Mannerisms that were seen several times in all
films deserve to be highlighted for the meaning they
could transmit in addition to those already reported (tension, nervousness, and anxiety) and for the
distraction they can generate. In general, the gesture of running hands through one’s hair is codified
as a sign used by women while dating or flirting;(8)
however, in the classroom context it is more related
to concern about physical appearance. In this particular instance, it can also be considered in relation
to concern about appearance to those who will see
the video.
A body posture that involves walking with
the chin up and hands crossed behind the back
indicates superiority and self-confidence; keeping hands in pockets may indicate that something is being hidden; scratching eyebrows, face,
nose, and mouth are signs related to filtering of
information or lying about what has been said,
saw, or heard.(9)
Audiovisual resources have an important role
in interpersonal distance and body posture. Some
professors tend to stand on one side of the room, as
close as possible to the audiovisual resources, or they
tend to be positioned laterally or back toward the
students for long periods of times, reading slides.
The function of audiovisual recourses is to illustrate,
clarify, and simplify presentations and, during their
use, eye contact must be kept with the audience/
Acta Paul Enferm. 2014; 27(3):194-9.
197
Nursing faculty’s opinion on effectiveness of non-verbal communication in the classroom
students. The professor/speaker should avoid, as
much as possible, reading the slides or speaking
while looking at the audiovisual resources.(10)
The head movements used most were the sign
of a positive response (inclining the head forward
indicating “yes” or affirmation) and the sign of negation (moving the head from one side to another,
indicating “no”).(9) In other cultures, such as in Bulgaria, some parts of the Greece, Yugoslavia, Turkey,
Iran, and Bengal, these movements have the opposite meaning (i.e., moving the head up and down
is a sign for “no,” and moving the head side to side
is a sign for “yes”).(11) In filming of the professors,
almost all used their head to indicate consenting,
which stimulated the students’ participation (positive movement).
During interactions, it is important to note if
the speaker is affirming something verbally but is
making a different movement with the head, indicating, for example, a hidden objection.(8) Furniture
organization in the classroom did not change, even
in the classrooms that enabled certain mobility and
had few students (maximum of eight), in order to
make the teaching-learning environment more welcoming, inclusive, and productive. Hence, learning
can be compromised in some classrooms even with
professors with an audible voice because there is too
much external noise.
With few exceptions in which professors touched
students, professors kept a distance that varied between personal distance (45 to 125 centimeters in
relation to the students in the first row) and social
distance (124 to 360 centimeters in relation to intermediary rows).(12) In large classroom and those
with more distance between rows, professors kept
a public distance, which necessitated using a microphone to amplify their voice. This relationship
could be different if professors circulate more in the
classroom, keeping a personal distance among more
students; show more accessibility and availability
in the learning-teaching process; facilitate contact,
interaction and flow of communication needed
to comprehend the content. Such improvements
would also help the students apply communicative
learning with patients, families, and multidisciplinary teams after they leave the classroom.
198
Acta Paul Enferm. 2014; 27(3):194-9.
Without a doubt, the professor is the person
who inspires and encourages students as they develop their communicative ability. In developing
this communicative ability, it is important that
contact with professor is a positive experience;
this is mainly achieved via the proximity to student in the classroom.
Professors mention that their incomprehension of the generation, unfolding of values and
lack of knowledge related to those they interact
with is a large obstacle for an autonomous pedagogical relationship.(2) For professors for whom
pedagogical autonomous relationships occur
easily, the knowledge domain and applicability
of non-verbal communication in classroom are
fundamental instruments.
The study of non-verbal communication requires knowledge, training, and observation of
others, but mainly self-knowledge.(5,13) The latter
is developed in several forms: body conscience,
thoughts, intentions and emotions, aligned with
objectives, interior serenity, internal balance, and
constant reflection.(13)
Conclusion
The opinion of nursing faculty regarding
non-verbal communication in the classroom
is general and unspecified, indicating inadequate application of this communication in the
classroom. The professors identified inefficient
non-verbal communication behavior less frequently than did the researcher.
Acknowledgements
We thank the Coordination for the Improvement
of Higher Education Personnel (CAPES) for the
master’s degree funding given to RoselyKalil de Freitas Castro Carrari de Amorim.
Collaborations
Amorim RKFCC contributed to the conception
of the project and the research and drafting of the
manuscript. Silva MJP contributed to conception
of the project, critical review to improve the manu-
Amorim RK, Silva MJ
script intellectual content and final approval of this
final version for publication.
6. Sgariboldi AR, Puggina AC, Silva MJ. Professors’ perception of
students’ feelings in the classroom: an analysis. Rev Esc Enferm USP.
2011;45(5):1201-7.
7. Edelstein RS, Luten TL, Ekman P, Goodman GS. Detecting lies in
children and adults. Law Hum Behav. 2006;30(1):1-10.
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1. Freire P. Pedagogy of freedom: ethics, democracy, and civic courage.
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9. Knapp ML, Hall JA. Nonverbal communication in human interaction.
Boston: Wadsworth, Cengage Learning; 2010.
2. Cortella MS. A escola e o conhecimento: fundamentos epistemológicos
e políticos. 14a ed. São Paulo: Cortez; 2011.
10.Longo A, Tierney C. Presentations Skills for the nurse Educator. J
Nurses Staff Dev. 2012;28(1):16-23.
3. Castro RB, Silva MJ. A comunicação não-verbal nas interações
enfermeiro-usuário em atendimentos de saúde mental. Rev Latinoam
Enferm. 2001;9(1):80-7.
11.Axtell RE. Essential do’s and taboos: the complete guide to
international business and leisure travel. New Jersey: John Wiley
& Sons; 2007.
4. Bosquetti LS, Braga EM. Communicative reactions of nursing students
regarding their first curricular internship period. Rev Esc Enferm USP.
2008;42(4):687-93.
12.Hall ET. Proxemics - a complex cultural language - a citation classic
commentary on a system for the notation of proxemic behavior by Hall
ET. Current Contents: Arts & Humanities. 1989;19(5):16.
5. Braga EM, Silva MJ. Competent communication: a view of nurse
experts in communication. Acta Paul Enferm. 2007;20(4):410-4.
13. Wood P. Secrets of the people whisperer: using the art of communication
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Acta Paul Enferm. 2014; 27(3):194-9.
199
Original Article
Prevalence of common mental
disorders in primary health care
Prevalência de transtorno mental comum na atenção primária
Roselma Lucchese1
Kamilla de Sousa1
Sarah do Prado Bonfin1
Ivânia Vera1
Fabiana Ribeiro Santana1
Keywords
Primary care nursing; Nursing research;
Mental health; Mental disorders/
epidemiology; Mental health assistance
Descritores
Enfermagem de atenção primária;
Pesquisa em enfermagem; Saúde
mental; Transtornos mentais/
epidemiologia; Assistência à saúde
mental
Submitted
January 16, 2014
Accepted
May 29, 2014
Ivânia Vera
Av. Doutor Lamartine Pinto de Avelar,
1120, Catalão, GO, Brazil.
Zip Code: 75704-020
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400035
200
Acta Paul Enferm. 2014; 27(3):200-7.
Abstract
Objective: To assess the prevalence of common mental disorder and its related factors in primary health care.
Methods: Cross-sectional study with 607 individuals in a primary health care service. The instrument of the
study was the Self Reporting Questionnaire 20.
Results: Out of the interviewed subjects, 31.47% showed greater probability of occurrence of a common
mental disorder. The following predictive variables were associated with a lower probability of occurrence
of common mental disorder: sex, being single, being a student or a worker with signed labor, having higher
education levels and income over four times the minimum wage. The variables associated with a higher
probability of occurrence of a common mental disorder were being self-employed, housewife, with children,
having lower education level and low income.
Conclusion: The prevalence of a common mental disorder was high and the associated factors were: being
female, divorced, Asian, aged between 18 and 59, housewife, with children, having four to seven years of
education, income up to one minimum age and living in a borrowed or donated house.
Resumo
Objetivo: Estimar a prevalência de transtorno mental comum e seus fatores associados em serviço de atenção
primária.
Métodos: Estudo transversal que incluiu 607 indivíduos em serviço de atenção primária. O instrumento de
pesquisa foi o questionário Self Report Questionnaire 20.
Resultados: Dos sujeitos entrevistados, 31,47% apresentaram maior probabilidade para transtorno mental
comum. Foram associadas à menor probabilidade de desenvolvimento do Transtorno Mental Comum as
variáveis preditoras: gênero, estado civil solteiro, ocupação estudante e com carteira assinada, maior nível
de escolaridade e renda acima de quatro salários mínimos. E, à maior probabilidade de desenvolvimento do
Transtorno Mental Comum as variáveis referir ocupação autônoma, do lar, ter filhos, menor escolaridade e
baixa renda.
Conclusão: A prevalencia de Transtorno Mental Comum foi alta e os fatores associados foram: no gênero
feminino, divorciado ou separado, cor da pele amarela, idade de 18 a 59 anos, ocupação do lar, com filhos, com
quatro a sete anos de estudo, renda de até um salário mínimo e residindo em moradia emprestada ou doada.
Universidade Federal de Goiás, Catalão, GO, Brazil.
Conflicts of interest: there are no conflicts of interest to declare.
1
Lucchese R, Sousa K, Bonfin SP, Vera I, Santana FR
Introduction
Estimates suggest that 14% of the overall load of
non-psychotic mental disorders come from neuropsychiatric disorders.(1,2) The chronic and disabling nature
of the disease is associated with this figure, which draws
the attention to its importance for public health. This
situation worsens when the mental disorder is associated with other morbidities, such as increased risk of
communicable or non-communicable diseases, and
contributes to expected and unexpected injuries.(1)
In that sense, the mental illness is followed by a
series of developments in biological, cultural, social,
economic and political aspects.(3) And among mental disorders, this study analyzed common mental
disorder (CMD), as it represents the most prevalent
disorder in the world population.(2,4)
The common mental disorder, also called non-psychotic mental disorder, is diagnosed when people are
mentally ill and present somatic symptoms such as irritation, fatigue, forgetfulness, concentration decrease,
anxiety and depression.(2,5) Global projections for 2030
seek to include these disturbances among the most disabling for human beings.(2) In Brazil, the prevalence
varies between 28.7 and 50% and is considered by specialists to be high, especially among women and elderly
people.(5-8) This information demonstrates the importance of tracking actions for possible cases of common
mental disorder within a community, particularly in
the primary health care and family health programs.(7)
Among the instruments used for its identification is the
Self Reporting Questionnaire 20 (SRQ-20), because of
its psychometric features in the breakdown of possible
cases of common mental disorder within the community, as well as its capacity to identify emotional disorders and needs in mental health.(5,9)
The SRQ-20 was validated in Brazil in 1986
and remodeled as a cutoff point for tracking common mental disorder within communities in 2008.
Since then, the instrument has been used with the
general population, with elderly people and people
with diabetes.(5,7-11)
However, the estimate of common mental disorder in primary health care deserves further research,
as health care, at this level, has the incorporation of
mental health practices as one of its challenges, and
this achievement will be consolidated after the real
picture has been properly analyzed.
The objective of this study is to assess the prevalence of common mental disorder and its related
factors in primary health care.
Methods
Sectional, observational and analytical study carried
out in a medium-sized municipality in the center-west of Brazil with significant socioeconomic
representativeness in the region.
A total of 1,440 families are registered in this
service, with approximately 4,810 people. Convenience sampling was used. Excluded individuals
were: those diagnosed with severe and persistent
mental disorder, with cognitive deficit or under the
influence of alcohol or other drugs, with non-matching address and individuals who were not located.
Data were collected between July 2011 and February 2012. The instrument used for data collection was
the Self Reporting Questionnaire (SRQ-20), which
is made up of 20 questions related to mental health
conditions in the last 30 days. The answers may be
“YES” or “NO”, and each “YES” corresponds to one
point. The result may vary from 0 (no probability of
common mental disorder) to 20 (very high probability
of common mental disorder). The cutoff point considered for this study was ≥7 for both genders.(5)
The individuals who had scores ≥7 were sent to
psychological care in a basic health care unit (UBS,
as per its acronym in Portuguese) of the health care
program network in the municipality or to a psychosocial care center.
Data were entered into Microsoft Excel for Windows® 2003-2007 spreadsheet after a double-check.
The analysis of data was performed by frequency and
relative frequency distribution, mean, and standard
deviation with the Software for Windows® Statistical
Package for Social Science for Windows (SPSS) version
15.0.(12) For the univariate analysis, the score ≥7 was
considered as outcome (higher probability of having
common mental disorder), also considering predictive
variables and the sociodemographic. For univariate
analysis between the probability of common mental
Acta Paul Enferm. 2014; 27(3):200-7.
201
disorder and predictive variables, the chi-square test
(c)2 or Fischer’s test was performed, with a significance
level of 5%. The effect measure used was the prevalence ratio (PR) and the respective confidence intervals
(CI95%). Factors were associated with the outcome
variable when p was lower than 0.05.(13)
The development of the study complied with
national and international ethical guidelines for
studies involving human beings.
Results
Study participants were 607 individuals, out of
which 31.47% had high probability of having
common mental disorder. The lowest SRQ-20
score was zero and the highest was 19 (YES), with
a 5.35 mean and 4.00 median (±4.177) for the
answer “YES”. Table 1 shows the characteristics of
the sample.
Table 1. Socioeconomic and demographic characterization
Variables
n(%)
≥7
SRQ 20
<7
SRQ 20
n(%)
n(%)
PR
CI95%
p-value
0.32
(0.20-0.50)
0.000*
Gender
Male
150(24.7)
18(12)
132(88.0)
Female
457(75.3)
173(37.9)
284(62.1)
With partner
417(68.7)
137(32.9)
280(67.1)
1.16
(0.89-1.51)
0.275
Single
102(16.8)
22(21.6)
80(78.4)
0.64
(0.44-0.95)
0.018*
0.97
(0.63-1.51)
0.893
1.00
Marital status
Widowed
49(8.1)
15(30.6)
34(69.4)
Divorced/Separated
39(6.4)
17(43.6)
22(56.4)
1.00
Color skin
White
310(51.1)
96(31.0)
214(69.0)
0.97
(0.77-1.22)
Black
48(7.9)
15(31.3)
33(68.8)
0.99
(0.64-1.54)
0.787
0.973
Brown
228(37.6)
71(31.1)
157(68.9)
0.98
(0.77-1.25)
0.893
Asian
21(3.5)
9(42.9)
12(57.1)
18 to 59 years
510(84.0)
163(32.0)
347(68.0)
≥60 years
97(16.0)
28(28.9)
69(71.1)
1.00
Age
1.11
(0.79-1.55)
0.547
1.00
Occupation
Student
40(6.6)
6(15.0)
34(85.0)
0.46
(0.22-0.97)
0.020*
Signed labor
118(19.4)
22(18.6)
96(81.4)
0.57
(0.38-0.85)
0.002*
Self-employed
132(21.7)
52(39.4)
80(60.6)
1.35
(1.04-1.73)
0.026*
Housewife
187(30.8)
77(41.2)
110(58.8)
1.52
(1.20-1.91)
0.000*
Unemployed/Retired/Pensioner
130(21.5)
34(26.2)
96(73.8)
Yes
525(86.5)
178(33.9)
347(66.1)
No
82(13.5)
13(15.9)
69(84.1)
1.00
With Cildren
2.14
(1.28-3.57)
0.001*
1.00
Years of education
None
33(5.4)
8(24.2)
25(75.8)
1 to 3 years
58(9.6)
18(31.0)
40(69.0)
1.01
(0.68-1.51)
1.00
0.954
4 to 7 years
159(26.2)
66(41.5)
93(58.5)
1.49
(1.17-1.81)
0.001*
8 to 11 years
275(45.3)
87(31.6)
188(68.4)
1.01
(0.80-1.28)
0.934
≥12 years
82(13.5)
12(14.6)
70(85.4)
0.43
(0.25-0.73)
0.000*
One resident
37(6.1)
14(37.8)
23(62.2)
2 to 3 people
107(17.6)
30(28.0)
77(72.0)
0.87
(0.63-1.21)
0.400
4 or more
463(76.3)
147(31.7)
316(68.3)
1.04
(0.79-1.37)
0.787
0.010*
Living in the household
1.00
Income
Up to 1 MW
69(11.4)
31(44.9)
38(55.1)
1.51
(1.13-2.02)
1 to 3 MW
401(66.1)
132(32.9)
269(67.1)
1.14
(0.88-1.48)
0.299
4 to 6 MW
121(19.9)
28(23.1)
93(76.9)
0.69
(0.49-0.98)
0.026*
15(2.5)
-
15(100.0)
0.00
(0.00-0.72)
0.003*
Owned
424(69.9)
125(29.5)
299(70.5)
0.86
(0.67-1.10)
0.240
Rented
162(26.7)
57(35.2)
105(64.8)
1.17
(0.91-1.50)
0.233
21(3.5)
9(42.9)
12(57.1)
≥7 MW
Housing
Borrowed/donated
MW - Minimum Wage; SRQ 20 - Self Report Questionnaire 20; PR - Prevalence Ratio; CI - Confidence Interval; Chi-square (c)2; *p<0.05; n=607
202
Acta Paul Enferm. 2014; 27(3):200-7.
1.00
100
90
80
70
60
50
40
30
20
10
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20
Yes
No
1- Do you often have headaches?; 2- Is your appetite poor?; 3- Do you sleep badly?; 4- Are you easily frightened?; 5- Do your hands shake?; 6- Do you feel
nervous, tense or worried?; 7- Is your digestion poor?; 8- Do you have trouble thinking clearly?; 9- Do you feel unhappy?; 10- Do you cry more than usual?;
11- Do you find it difficult to enjoy your daily activities?; 12- Do you find it difficult to make decisions?; 13- Is your daily work suffering?; 14- Are you unable
to play a useful role in life?; 15- Have you lost interest in things?; 16- Do you feel that you are a worthless person?; 17- Has the thought of ending your life
been on your mind?; 18- Do you feel tired all the time?; 19- Are you easily tired?; 20- Do you have uncomfortable feelings in your stomach?
Figure 1. Affirmative and negative answers among the 191 individuals who had a score of ≥ 7
After univariate analysis, there was an association with the outcome in the following predictive
variables: gender p=0.000 (PR:0.32 [CI 95%: 0.200.50]); single marital status p=0.018 (PR:0.64 [CI
95%: 0.44- 0.95]); occupation student p=0.020
(PR:0.46 [CI 95%: 0.22- 0.97]); signed labor
p=0.002 (PR:0.57 [CI 95%: 0.38- 0.85]); occupation self-employed p=0.026 (PR:1.35 [CI 95%:
1.04- 1.73]); housewife p=0.000 (PR:1.52 [CI
95%: 1.20- 1.91]); with children p=0.001 (PR:2.14
[CI 95%: 1.28- 3.57]); 4 to 7 years of education
p=0.001 (PR:1.49 [CI 95%: 1.17- 1.81]); ≥12 years
of education p=0.000 (PR:0.43 [CI 95%: 0.250.73]); income up to 1 minimum wage p=0.010
(PR:1.51 [CI 95%: 1.13- 2.02]); income of 4 to 6
minimum wages p=0.026 (PR:0.69 [CI 95%: 0.490.98]); income of ≥7 minimum wages p=0.003
(PR:0.00 [CI 95%: 0.00- 0.72]).
Regarding the questions explored by the
SRQ-20, figure 1 describes the negative and affir-
mative answers among the 191 subjects who had
a score of ≥7.
Of the answers obtained with the tracking instrument of common mental disorder, the answer
YES prevailed for: feeling nervous, tense or worried
(65.7%), feeling unhappy (41.4%) and often having
headaches (39.4%). On the other hand, the highest
prevalence of NO answers was for: the thought of
ending life (94.9%), suffering daily work (92.9%)
and feeling worthless (88.9%).
Discussion
The limitations involving this study include its
sectional methodological design, which does
not allow inferring a causal connection, as it
describes the phenomenon at a given place and
time. Another limitation concerns the convenience sampling technique.
Acta Paul Enferm. 2014; 27(3):200-7.
203
However, the results of the study estimated the
prevalence of common mental disorder and described relevant characteristics of people who obtained a score of ≥7 in the SRQ-20, such as symptoms related to depression, anxiety and somatotropics, which indicate the need for better organization of primary health care and family care in the
development of mental health promotion. These
aspects contribute to the development of nursing
practices, as the instrument used was low-cost, easy
to interpret and can be largely applied by the health
staff, especially the nursing staff in the tracking of
non-psychotic mental disorders, in order to revert
the underreporting of this morbidity, as noted by
some authors.(5,7)
Regarding the results, this study showed that
the prevalence of suspected cases of common mental disorder within the population studied was
31.47%, which confirms the results obtained by
other studies carried out in other parts of Brazil using the SRQ-20 test.(5,7,11)
In these studies, the prevalence of non-psychotic disorders varied 28.7% in a municipality of Santa Cruz do Sul, southern Brazil; 29.9% in Feira de
Santana, northeastern region; 39.44% in Blumenau, southern region.(5,10,11) The highest percentage
was found in the municipality of São João Del-Rei,
southeastern region, with 43.70%.(7)
When the sociodemographic particularities
were considered, a lower prevalence was observed
among men regarding non-psychotic morbidities
when compared to women; and this was also observed in other studies.(2,5,7,10-13)
Considering the strong relationship between
men and work, it is understood that any mistake
or failure may affect the social and personal context, resulting in emotional/psychological problems. Nevertheless, a closer link between women
and common mental disorder can be established
due to work and family responsibility, as they frequently give up self-care to dedicate themselves
to others, resulting in dismay, anxiety, frustration, angst, illness, and most of all, the occurrence of mental disorders.(13,14)
After a bibliographic review of the literature,
the systematic knowledge regarding inequalities of
204
Acta Paul Enferm. 2014; 27(3):200-7.
gender and common mental disorder revealed that
high rates of disorders in women result from their
depreciation within society, from weariness due to
workload both at home and at work, and from violence they suffered from their partners. Moreover,
women easily notice their illness, promptly report
their symptoms and search for health services more
frequently than men.(3)
Regarding marital status, the association of
common mental disorder with being single revealed an unprecedented event in this study when
compared with previous ones, which presented
an association of common mental disorder with
divorced or separated and widowed individuals.
(11,12)
There is a contradiction regarding a significant statistical association of marital status with
common mental disorder when we say that family
coexistence is essential for the individual’s conception as a social element, as it is within the family environment that one outlines the constitution
of the individual, the organization of the identity,
the psychological development and personality.(12)
Based on the derivatives related to occupation,
the association in this study of common mental
disorder with the predictive variables of being a
“housewife” and “self-employed” corresponds to
the categories with the largest predisposition to
common mental disorder. In that sense, housewives perform household duties and are closely
related to risk variables for depression and anxiety. This risk is explained by the fact that these
women, by being isolated at home, are forced
to give up on their professional satisfaction and
consequently on their socialization.(15)
On the other hand, most self-employed
workers, who can be classified as informal workers since they do not have a signed labor, experience situations such as uncertainty regarding
their working situation, income restraint, lack of
social benefits and lack of protection from labor
legislation; and all of these factors trigger anxiety and depression.(3) Therefore, when it comes
to the “occupation” variable, the individuals who
showed lower probability of having common
mental disorder were students and individuals
with a signed labor contract.
Another significant statistical association
with common mental disorder in this study was
the predictive variable “with children”. The disorders resulting from the duality of roles played,
that comprehends both the upbringing of children and responsibilities regarding profession,
were confirmed by the results of a previous research, which revealed that having children may
be a risk factor for the occurrence of common
mental disorder among female workers but not
among housewives.(16)
Regarding the years of education, there was a
prevalence of the interest condition in the group
with common mental disorder in relation to the
non-exposed group, that is, which did not present common mental disorder in two periods of
education. The interviewees who declared having studied for 4 to 7 years showed lower probability of having common mental disorder. This
finding does not differ substantially from that
described in another study with individuals in
primary health care who had the same education
level.(7)
A greater number of years of education also
represented a lower probability of having common mental disorder, so those who have higher education have fewer chances of developing
non-severe disorders. Generally speaking, this
inverse linear correlation between the chances of
having a disorder and education level is also revealed by other researchers.(17)
On the other hand, fewer years of education
is a factor that is closely related to the occurrence
of non-psychotic disorder. This fact implies in
difficulties in entering the work market, low income, lack of appreciation and uncertain life conditions; and it may be considered to be the root
of other social problems resulting in poor quality
of life and consequent psychological problems in
the future.(17)
In the current social context, many children
that come from low income families usually drop
out of school as they need to work to contribute
to the household income. The fact that these families have low income is mostly due to the fact that
parents did not have a higher level of labor inser-
tion. Consequently, this problem becomes cyclical
and affects general health conditions and essentially
mental health.(17)
Regarding monthly incomes, individuals who
had up to one minimum wage of income showed
higher probability of developing common mental disorder. This finding also came up in another
research in which subjects with incomes under or
equal to one minimum wage were more likely to
have non-psychotic disorders.(11)
An inverse relationship regarding wealthier people (more than 4 MW) was also observed and confirmed by a previous study, in which lower family
incomes of participants indicated more probability
for mental disorders.(7)
This relationship was also highlighted by the
indication that people who lived with less than
one minimum wage were four times more likely to have common mental disorder than people
who lived with more than three minimum wages.(16) Therefore, low incomes are related to high
rates of psychological problems arousing from a
decrease of power, greater uncertainty, a painful
compliance with social rules, stressful events in
daily life that result in low self-esteem and, consequently, in greater chances of developing mental disorders.(3,7)
Regarding the questionnaire, from the answers
obtained with the help of SRQ-20 to indicate common mental disorder, it is important to highlight
the prevalence of an anxious-depressed mood resulting from feelings of nervousness, tension or
worries, along with somatic symptoms and frequent
headaches. This set of symptoms also prevailed in
another study.(15)
Individuals who were more likely to develop a
common mental disorder have different levels of
anxious, depressive or somatoform disorders.(2) In
view of this situation, it is recommended that the
search for common mental disorder be systematized
in primary health care, as well as specific mental
health care actions at this level.(17)
Consequently, within the population studied, a lower prevalence of thoughts such as giving
an end to life or feeling worthless was observed.
From this analysis, there is a certain profile of
Acta Paul Enferm. 2014; 27(3):200-7.
205
individuals that stands out: those who are more
affected by an anxious-depressive mood and less
by suicidal thoughts.
A higher rate of “NO” answers was observed for
symptoms of decrease of vital energy in the item
“suffering daily work”. Despite the fact that the
“housewife” and “self-employed” occupations presented an association with common mental disorder through the univariate analysis, occupation was
not considered to be a relevant factor for the decrease of vital energy.
In that sense, it is understood that the occupation appears in the health-illness process proportionally to the degree of expectations experienced
by the worker. Factors such as overload, underload,
lack of control over work, gap between control
groups and subordinate staff, social withdrawal in
the work environment, role conflicts, social disorder and absence of social support can cause physical
and mental suffering.(18)
Conclusion
The prevalence of common mental disorder was
higher among women, divorced individuals, Asian,
aged between 18 and 59 years, housewives, individuals with children, having four to seven years of education, income up to one minimum age and living
in a borrowed or donated house.
Collaborations
Lucchese R participated in the conception of the
project, analysis and interpretation of data, writing of the article, critical review of the content
and final approval of the version to be published.
Santana FR participated in the conception of the
project, critical review of the content and final
approval of the version to be published. Vera I
participated in the analysis and interpretation of
data, critical review of the content and final approval of the version to be published. Sousa K
and Bonfim SP were field researchers, and participated in the writing of the article, critical review
of the content and final approval of the version
to be published.
206
Acta Paul Enferm. 2014; 27(3):200-7.
References
1. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al.
No health without mental health. Global Mental Health. Lancet.
2007;370:859-77.
2. Skapinakis P, Bellos S, Koupidis S, Grammatikopoulos L, Theodorakis
PN, Mavreas V. Prevalence and sociodemographic associations of
common mental disorders in a nationally representative sample of the
general population of Greece. BMC Psychiatry. 2013;13:163.
3. Ludemir AB. [Class and gender inequalities and mental health in the
cities]. Physis. 2008; 18(3):451-67. Portuguese.
4. Fone D, Greene G, Farewell D, White J, Kelly M, Dunstan F. [Common
mental disorders, neighbourhood income inequality and income
deprivation: small-area multilevel analysis]. Br J
Psychiatry. 2013;202(4): 286–293.
5. Gonçalves DM, Stein A T, Kapczinski F. [Performance of the SelfReporting Questionnaire as a psychiatric screening questionnaire: a
comparative study with Structured Clinical Interview for DSM-IV-TR].
Cad Saúde Pública. 2008; 24(2): 380-90. Portuguese
6. Fortes S, Lopes CS, Villano LA, Campos MR, Gonçalves DA, Mari JJ.
[Common mental disorders in Petrópolis-RJ: a challenge to integrate
mental health into primary care strategies]. Rev Bras Psiquiatr. 2011;
33(2):150-6. Portuguese.
7. Moreira JK, Bandeira M; Cardoso CS; Scalon JD. [Prevalence of
common mental disorders in the population attended by the Family
Health Program]. J Bras Psiquiatr. 2011;60(3):221-6. Portuguese.
8. Borim FS, Barros MB, Botega NJ. [Common mental disorders among
elderly individuals: a population-based study in Campinas, São Paulo
State, Brazil]. Cad Saúde Coletiva. 2013;29(7):1415-26. Portuguese.
9. Santos KO, Araújo TM, Oliveira NF. [Factor structure and internal
consistency of the Self- Reporting questionnaire (SRQ-20) in an urban
population]. Cad Saúde Pública. 2009;25(1):214-22. Portuguese.
10. Helena ET, Lasagno BG, Vieira R. [Prevalence of non-psychotic mental
disorders and associated factors in people with hypertension and/or
diabetes from Family Health Units in Blumenau, Santa Catarina, Brazil].
Rev Bras Med Fam Comunidade. 2010; 17(5): 42-7. Portuguese.
11. Rocha SV, Almeida MM, Araújo TM, Júnior JS. [Prevalence of common
mental disorders among the residents of urban areas in Feira de
Santana, Bahia]. Rev Bras Epidemiol. 2010;13(4):630-40. Portuguese.
12. Andrade FB, Bezerra AI, Pontes AL, Ferreira Filha MO, Vianna RP, Dias MD,
et al. [Mental health in the basic attention: an epidemic study based on the
risk focus]. Rev Bras Enferm. 2009;62(5):675-80. Portuguese.
13. Carlotto MS, Amazarray MR, Chinazzo I, Taborda L. [Common Mental
Disorders and associated factors among workers: an analysis from
a gender perspective]. Cad Saúde Coletiva. 2011;19(2): 172-8.
Portuguese.
14.Batista JB, Carlotto MS, Coutinho AS, Nobre Neto FD, Augusto LG.
[Basic school teacher’s health: gender analysis]. Cad Saúde Coletiva.
2009;17(3):657-74. Portuguese.
15.Araújo TM, Almeida MM, Santana CC, Araújo EM, Pinho PS.
[Psychological disorders among women: a comparative study between
housewives and workers]. Rev Enferm UERJ. 2006;14(2):260-9.
Portuguese.
16. Farias MD, Araújo TM. [Common mental disorders among workers in
the urban area of Feira de Santana – Bahia-Brazil]. Rev Bras Saúde
Ocup. 2011; 36 (123): 25-39. Portuguese.
17.Fonseca ML, Guimarães MB, Vasconcelos EM. [Diffuse distress
and common mental disorders: a bibliographic review]. Rev APS.
2008;11(3): 285-94. Portuguese.
18. Souza SF, Carvalho FM, Araújo TM, Porto LA. [Psychosocial factors of
work and mental disorders in electricians] Rev Saúde Pública. 2010;
44(4):710-7. Portuguese.
Acta Paul Enferm. 2014; 27(3):200-7.
207
Original Article
Prevalence of depressive symptoms
and associated factors among
institutionalized elderly
Prevalência de sintomatologia depressiva e fatores
associados entre idosos institucionalizados
Márcia Carréra Campos Leal1
João Luis Alves Apóstolo2
Aída Maria de Oliveira Cruz Mendes2
Ana Paula de Oliveira Marques1
Keywords
Geriatric nursing, Nursing assessment;
Aging; Aged; Depression; Prevalence
Descritores
Enfermagem geriátrica; Avaliação em
enfermagem; Envelhecimento; Idoso;
Depressão; Prevalência
Submitted
January 14, 2014
Accepted
May 26, 2014
Abstract
Objective: Determining the prevalence of depressive symptoms and associated factors in institutionalized elderly.
Methods: Cross-sectional study that included 211 elderly from Brazil and 342 from Portugal, all residing in
long-stay institutions. The survey instrument was the Geriatric Depression Scale.
Results: The prevalence of depressive symptoms was found among 49.76% of the elderly in Brazil and in
61.40% of the Portuguese seniors. The Brazilian elderly with depressive symptomatology have the single
marital status, low number of years of study and gender as main associated factors. Among the Portuguese
elderly, the main associated factor was the age over 70 years.
Conclusion: The prevalence of depressive symptoms was high and its early recognition may contribute to the
quality of life of institutionalized elderly.
Resumo
Objetivo: Conhecer a prevalência da sintomatologia depressiva e fatores associados em idosos institucionalizados.
Métodos: Estudo transversal que incluiu 211 idosos brasileiros e 342 idosos portugueses, residentes em
instituições de longa permanência. O instrumento de pesquisa foi a Escala de Depressão Geriátrica.
Resultados: A prevalência de sintomatologia depressiva encontrada foi 49,76% entre idosos brasileiros e
61,40% em portugueses. Idosos brasileiros com sintomatologia depressiva têm como principais fatores
associados o estado civil solteiro, o baixo número de anos de estudo e o sexo. Entre idosos portugueses o
principal fator associado foi a idade maior do que 70 anos.
Conclusão: A prevalência da sintomatologia depressiva foi alta e o seu reconhecimento precoce pode
contribuir para a qualidade de vida e idosos institucionalizados.
Márcia Carréra Campos Leal
Prof. Moraes Rego Avenue, 1235,
Recife, PE, Brazil. Zip Code: 50670-901
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400036
208
Acta Paul Enferm. 2014; 27(3):208-14.
Universidade Federal de Pernambuco, Recife, PE, Brazil.
Escola Superior de Enfermagem, Universidade de Coimbra, Coimbra, Portugal.
Conflicts of interest: no conflicts of interest to declare.
1
2
Leal MC, Apóstolo JL, Mendes AM, Marques AP
Introduction
Population aging is a global reality that is happening in different countries, including Brazil and Portugal, although each of these countries is at different stages of this transition. Thus, within a few years
we will have more people aged over 60 years, with
a larger number of people reaching older ages, exceeding the life expectancy predicted by experts.(1)
The World Health Organization considers as elderly in developing countries any person older than
60 years, and in developed countries, people aged
over 65 years.(2) According to the same source, there
is a statistical forecast for 2025 of an elderly population of 1.2 billion people in the world. A curious
fact is that the older population, those aged over 80
years, will be the fastest growing age group.
According to the Brazilian Institute of Geography and Statistics (IBGE - Instituto Brasileiro
de Geografia e Estatística),(3) the Brazilian population is 190,732,694 people, with about 10%
aged over 60 years. Life expectancy for women is
77 years and for men is 69.4 years. According to
the National Institute of Statistics, in Portugal(4)
there are 10,561,614 inhabitants, among which
19% are elderly. The European country has a life
expectancy of 81.8 years for women and of 75.8
years for men.
The strategy for health promotion aimed at
the aging population in Brazil is supported by the
National Health Policy for the Elderly.(5) And in
Portugal, through the National Programme for the
Health of the Elderly.(6) Due to the increasing number of elderly and the difficulties faced by families in
the task of caring (related to changes in family structure, such as the emergence of smaller families and
an increasing individual mobility because of work
obligations), arises the necessity for Institutions for
the Aged, which are places of comprehensive care
for older people who are unable to stay with their
families or in their own homes.
The aging process causes changes in the pattern
of diseases and in the frequency of disabilities.(7)
The physical, cognitive and sensory functions are
weakened, leading to deterioration of functional
abilities.(8) Therefore, a high prevalence of mental
disorders is noticeable at the old age, among which
predominates the depression.(9)
According to the literature, depression is
common in old age, but contrary to popular
opinion, is not part of the natural aging process.
In most cases, depression is underdiagnosed and
undertreated. It is observed that among institutionalized elderly, depression often remains
undiagnosed and untreated, especially in institutions without a team of professionals with
knowledge and skills to identify patients at risk.
Hence, the necessity to enable these professionals to recognize the most common ways in which
the depressive syndromes are presented.(10) Thus,
in relation to affective disorders, depression imposes itself as the most frequent in the elderly,
currently becoming the leading cause of disability worldwide. According to Apóstolo et al.,(11)
depression is responsible for 6.2% of the morbidity rate in the European region of the World
Health Organization.
Considering the increase of the elderly population worldwide, we understand the need for studies involving different countries, in order to track
changes and possible differences in the dynamics of
aging. Thus, enabling improvements in the life condition of the elderly.
Based on the above, this study was carried out
in two different scenarios, assessing the elderly
in a Latin American developing country and in
a developed European country, aiming at evaluating and comparing the depressive symptoms
and socio-demographic factors among institutionalized elderly in Brazil and Portugal. The hypothesis was that the comparative analysis would
enable knowing the greater or lesser proximity
of the two countries regarding the prevalence of
depressive symptoms and associated factors, inferring if these can serve as indicators of trends
or not. I.e., under a specific parameter, the analysis should permit evaluating the current demographic and epidemiological transition stage of
Brazil in relation to Portugal.
This study aimed at knowing the prevalence of
depressive symptoms and socio-demographic factors in institutionalized elderly.
Acta Paul Enferm. 2014; 27(3):208-14.
209
Prevalence of depressive symptoms and associated factors among institutionalized elderly
Methods
This is a cross-sectional study carried out in two scenarios: the city of Recife, northeastern Brazil and
the city of Coimbra, in Portugal. The sample consisted of 211 Brazilian seniors and 342 Portuguese
seniors aged over 60 years and residents of long-stay
institutions. The proportional stratified sampling
technique was used to select the sample, allowing
the choice of its components depending on the actual distribution of strata in the population.
Data collection was obtained through interviews
with socio-demographic features and the Geriatric
Depression Scale of 15 items. The interviews with
the Portuguese population were conducted by researchers at the Research Unit in Health Sciences:
Nursing, of the Escola Superior de Enfermagem de
Coimbra. For the Brazilian population, the interviews were conducted by researchers of the Research
Group – Health of the Elderly of the Universidade
Federal de Pernambuco.
The presence of depressive symptoms was assessed using the Geriatric Depression Scale with 15
items, a short version of the original scale.(12-14)
The Geriatric Depression Scale with 15 items
is one of the most used tools for detecting depression in the elderly. Several studies have shown that
this scale provides valid and reliable measures for
the assessment of depressive disorders, thus justifying its choice. The cutoff used for suspected depression was > 5.
The Statistical Package for the Social Sciences, version 16.0 was used for data management.
After data collection, the information was entered into a database of the statistical program.
First, the data were descriptively analyzed with
dispersion measures for the numeric variable
of age. Tables and graphs were generated for
the subsequent bivariate analysis in each of the
countries, considering the depressive symptoms
as the dependent variable. After checking the associations, the profile analysis was done only of
respondents with depressive symptoms. In order
to define the most important features, a classification/decision tree was generated based on the
origin of the respondents, i.e., Brazil or Portugal,
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Acta Paul Enferm. 2014; 27(3):208-14.
through computer simulations, using the aforementioned statistical tool.
The development of study followed the national
and international standards of ethics in research involving human beings.
Results
Using the chi-square test to assess the association
between the dependent variables and depressive
symptoms in each country separately, and considering a significance level of 5%, the table 1 shows
that in Brazil the hypothesis of independence of depressive symptoms in relation to gender and age was
rejected. When evaluating the results of the same
statistical tests in Portugal, the hypothesis of independence of depressive symptoms with any of the
variables was not rejected.
As the p-value of the Pearson’s chi-squared
test for the intersection between the depressive
symptoms variable and the country of respondents was lower than 0.05 (5%), we can consider
there is an association between them. For this
reason, we performed an analysis to define the
profile of the elderly with depressive symptoms
in each country.
It is noteworthy that the percentage distribution of each category of the analyzed variables is
different when considering Brazil and Portugal
separately. (Table 2)
In order to assess the main characteristics of elderly patients with depressive symptomatology in
Brazil and Portugal and recommend an appropriate classification, a decision/classification tree was
proposed using the Statistical Package for the Social
Sciences version 16.0. The growth algorithm chosen was the “EXHAUSTIVE CHAID,” which is a
variation of the standard algorithm “CHAID” that
is based on the existing associations in each of the
growth steps, through the Pearson’s chi-squared test.
At the first level, it is noted the separation by marital status: most seniors with depressive symptomatology in Brazil (54 cases) was observed in the category of
singles, while in Portugal most respondents (183 cases)
are widowed or maintain stable relationships.
Table 1. Factors associated with depressive symptoms
Table 2. Positive depressive symptomatology
Country
Variables
Brazil
Frequency
(%)
Country
Portugal
p-value
Frequency
(%)
p-value
Brazil
Portugal
Frequency
(%)
Frequency
(%)
Female
85(81.0)
131(62.4)
Male
20(19.0)
79(37.6)
Variables
Gender
Female
147(69.67)
0.0
215(62.87)
Male
64(30.33)
0.21
127(37.13)
0.82
Gender
Age
60 |- 70 years
61(28.91)
70 |- 80 years
72(34.12)
80 |- 90 years
57(27.01)
90 and over
24(7.02)
0.18
0.96
Age
85(24.85)
176(51.46)
60 |- 70 years
29(27.6)
15(7.1)
21(9.95)
57(16.67)
70 |- 80 years
33(31.4)
54(25.7)
80 |- 90 years
28(26.7)
107(51.0)
18(8.53)
70(20.47)
90 |-
15(14.3)
34(16.2)
Single
113(53.55)
44(12.87)
Widowed
55(26.07)
Separated/ Divorced
24(11.37)
67(19.59)
7(6.7)
41(19.5)
1(0.47)
0(0.00)
Single
54(51.4)
27(12.9)
Widowed
27(25.7)
98(46.7)
Separated/ Divorced
17(16.2)
44(21.0)
01 |- 05
42(40.0)
141(67.1)
05 |- 09
9(8.6)
8(3.8)
09 |- 12
7(6.7)
7(3.3)
12 or more
3(2.9)
3(1.4)
44(41.9)
51(24.3)
Marital status
Married/ Living with partner
Not informed
0.08
0.86
Marital status
161(47.08)
Married/ Living with partner
Years of education/study
01 |- 05
86(40.76)
219(64.04)
05 |- 09
28(13.27)
15(4.39)
09 |- 12
17(8.06)
11(3.22)
12 or more
8(3.79)
6(1.75)
72(34.12)
91(26.61)
None/Unknown/Not informed
0.61
Depressive symptomatology
With
105(49.76)
210(61.40)
Without
106(50.24)
132(38.60)
At the second level, when it comes to Brazil,
most of the respondents with depressive symptoms
is illiterate or has few years of study (32 cases), while
in Portugal, in the second level of the tree, most of
the elderly is older than 70 years (171 cases).
It is only at the third level that the Portuguese
elderly appear to be more sensitive to the few years
of study (81 cases) and the Brazilians with respect to
the female gender (13 cases). Brazilian elderly with
depressive symptomatology have as main associated
factors, the single marital status, the few years of study
and gender. In contrast, the Portuguese elderly have
as main factors associated with depressive symptoms
not belonging to the single marital status and age older
than 70 years. Education, which appears as the second
most important characteristic among Brazilians, is the
third strongest among the Portuguese elderly.
Years of education/study
None/Not informed
In order to verify if the age of respondents with
depressive symptoms was the same in the two countries, the t-test was applied to determine the equality of means. The Brazilian mean obtained was of
81.14 years and the Portuguese mean was of 82.22
years. The statistical test generated a p-value of
0.6855, i.e., considering a significance level of 5%,
there is no statistical evidence that the mean ages
among patients of Brazil and Portugal are different.
Therefore, in the studied sample the most important factor for Brazilian respondents was the
marital status, assuming that singles seem to be at
higher risk of depression, while in Portugal, being
single does not appear to be a risk factor as significant, if compared to Brazil. The average age of the
respondents in both countries was statistically the
same, but the majority of Portuguese respondents
Acta Paul Enferm. 2014; 27(3):208-14.
211
Figure 1. Classification/decision tree
with depression was aged between 70 and 90 years,
whereas, among Brazilians, the distribution was
more uniform in the various categorizations of age
(Figura 1).
Discussion
The limitations of this study results are related to
the cross-sectional design that does not allow establishing relations of cause and effect.
The importance of the results obtained for nursing professionals together with the health team is
noteworthy. Acquiring knowledge about the aging
process and the diseases that can affect the elder-
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Acta Paul Enferm. 2014; 27(3):208-14.
ly, including depression, makes these professionals
more alert, in the sense of identifying the needs of
the elderly, minimizing the existing difficulties and
favoring a better quality of life.
Regarding gender, the sample of institutionalized elderly, both in the cities of Recife and Coimbra, showed a higher percentage of women, of
69.67% and 62.87% respectively, which is the same
data found in other studies, reinforcing the feminization of ageing.(15,16)
Regarding the age factor, it was observed that
in Recife the highest prevalence was found in the
age group of 70-80 years (34.12%) and that, in Coimbra, it was between 80 and 90 years (51.46%),
which corresponds to a higher life expectancy in de-
veloped countries. According to data from the Brazilian Institute of Geography and Statistics,(3) life
expectancy for women is 77 years and for men, 69.4
years. In Portugal, the National Institute of Statistics (4) has a life expectancy of 81.8 years for women
and of 75.8 years for men. These differences, however, do not hide the common trend for both countries of institutionalization occurring at older ages.
In relation to marital status, the single and widowed participants of Brazilian institutions reached a
percentage of 79.62%, while in Portugal the widowed
and separated/divorced participants reached 66.65%.
The result corroborates other studies and justifies the
search for these institutions at that time of life when
finding oneself alone. This search may also occur as a
personal initiative, often due to external pressures, fear
of urban violence, exclusion of the family, and especially for believing in the quality of care provided in
Long-Stay Institutions for the Elderly.(15,17)
Considering the level of education of the participants, we found that the two groups have low level of education: a high percentage, of approximately
74.88% of Brazilians and 90.65% of Portuguese, have
up to 5 years of study. We can consider that the low
level of education of institutionalized elderly is probably due to the difficulty of access to education experienced a few decades ago, especially for women.(16,18,19)
We believe that the institutionalization of the elderly can be a potentiating condition of depression,
because by living in this new environment, isolated
from their social life and away from their families,
they need to adapt to all these changes. According to
Salgueiro,(20) the elderly leave their homes, no longer
have their own time, lose their autonomy and become dependent on third parties, which could trigger depressive states. Thus, we find in national and
international scientific literature a high prevalence of
depression in institutionalized elderly.
Regarding the Brazilian institutionalized elderly,
the prevalence of depressive symptoms is equivalent to
49.76%, a result that approaches other studies such as
the one by Soares et al.,(16) that obtained an extremely
high prevalence of 73.7% in institutionalized elderly,
as well as the study by Maciel and Guerra,(21) with a
prevalence of depressive symptoms of 25.5% for noninstitutionalized elderly.
The prevalence of depressive symptoms in the Portuguese studied population was 61.40%. These values
corroborate several studies, including the one by Vaz
and Gaspar,(15) with prevalence of 47%. The information suggests that living in institutions probably requires actions that plan the comprehensive attention
to the elderly more effectively, making it necessary to
train the technical team who is responsible for the care.
We emphasize that in addition to technical skills, we
can not fail to encourage these professionals to cultivate
a more human look to the limitations of the elderly.
They must be reminded that caring is an act of love.
Analyzing these data, we can corroborate the national and international studies, in which the number
of institutionalized elderly with depressive symptoms is
high, ranging from 25% to 80%.
For Brazilian institutionalized elderly, the single
marital status is a risk factor in relation to depressive symptoms. This fact is rarely discussed because
in most studies, what is observed are gender issues,
education and economic factors, i.e., an increased
risk among women of low income and low education.(14,21) The environment of long-stay institutions
provides challenges to residents and may favor the
development of depressive symptoms. Therefore,
the awareness of the diagnosis of depression in the
institutional context by the technicians responsible
for the care is of fundamental importance. The recognition of depression in the elderly should contribute to the development of strategies, favoring
the effectiveness of treatment and, consequently,
improving the Quality of Life of the Elderly.
Conclusion
The prevalence of depressive symptoms was high
and its early recognition may contribute to the
quality of life of institutionalized elderly.
Collaborations
Leal MCC and Apóstolo JLA contributed to the
project design, study execution, analysis and interpretation of data, drafting the article and final
approval of the version to be published. Mendes
AMOC and Marques APO contributed to the projActa Paul Enferm. 2014; 27(3):208-14.
213
ect design, drafting the article and critical revision
for important intellectual content.
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xmain?xpid=CENSOS&xpgid=censos2011_apresentacao.
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instituições de longa permanência e processos adaptativos: um estudo
de caso. Texto & Contexto Enferm. 2008;17(2):258-65.
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idosos institucionalizados. Rev Bras Ativ Fís & Saúde. 2011;16(2):120-4.
6. Portugal. Ministério da Saúde. Direcção-Geral da Saúde. Divisão de
Doenças Genéticas, Crónicas e Geriátricas. Programa Nacional para a
Saúde das Pessoas Idosas [Internet]. Lisboa: Direção-Geral da Saúde; 2004
[citado 2013 23 Dez]. Disponível em: http://www.portaldasaude.pt/NR/
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caídas en una muestra de adultos mayores pobres en México. Salud
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Original Article
Ethical conflicts experienced by nurses
during the organ donation process
Conflitos éticos vivenciados por enfermeiros
no processo de doação de órgãos
Mara Nogueira de Araújo1
Maria Cristina Komatsu Braga Massarollo1
Keywords
Ethics, nursing; Transplantation; Direct
tissue donation; Conflict (Psychology);
Qualitative research
Descritores
Ética em Enfermagem; Transplante;
Doção dirigida de tecidos; Conflito
(Psicologia); Pesquisa qualitativa
Submitted
January 13, 2014
Accepted
April 29, 2014
Mara Nogueira de Araújo
Doutor Enéas de Carvalho Aguiar
Avenue, 419, São Paulo, SP, Brazil.
Zip Code: 05403-000
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400037
Abstract
Objective: To determine ethical conflicts experienced by nursing during the organ donation process.
Methods: This qualitative study used the content analysis approach developed by Bardin. We interviewed
eleven nurses who had cared for potential donors of organs for transplantation. Four questions were used to
guide the interview.
Results: After analysis, five categories emerged: difficulty in accepting brain death; non-acceptance of the
multidisciplinary team for withdrawing mechanical ventilation of the non-donor patient after brain death;
difficulty of the multidisciplinary team during the organ donation process; and situations that can interfere with
the organ donation process and decision making in ethical conflicts.
Conclusion: Ethical conflicts experienced by nurses during the organ donation process were difficulty of health
care professionals in accepting brain death as the death of the individual, non-acceptance of withdrawing
mechanical ventilation in non-donor patients after brain death, lack of knowledge to perform the brain
death protocol, lack of commitment, negligence in care for potential donors, scarcity of human and material
resources, religion, and lack of communication.
Resumo
Objetivo: Conhecer os conflitos éticos vivenciados pelos enfermeiros no processo de doação de órgãos.
Métodos: Pesquisa qualitativa utilizando a análise de conteúdo de Bardin. Foram entrevistados onze
enfermeiros, com experiência na assistência a potenciais doadores de órgãos para transplante. Foram
utilizadas quatro questões norteadoras.
Resultados: Emergiram cinco categorias: dificuldade em aceitar a morte encefálica; não aceitação da equipe
multiprofissional de desconectar o ventilador mecânico do paciente em morte encefálica não doador de
órgãos; dificuldades da equipe multiprofissional durante o processo de doação de órgãos; situações que
podem interferir no processo de doação de órgãos e Tomada de decisão frente a conflitos éticos.
Conclusão: Os conflitos éticos vivenciados pelos enfermeiros no processo de doação de órgãos foram: a
dificuldade do profissional em aceitar a morte encefálica como morte do individuo, a não aceitação em
desconectar o ventilador mecânico do paciente em morte encefálica e não doador de órgãos, o desconhecimento
para a realização do protocolo de morte encefálica, a falta de comprometimento, o descaso no cuidado com
o potencial doador a escassez de recursos humanos e materiais a crença religiosa e a falha na comunicação.
Conflicts of interest: none reported.
1
Acta Paul Enferm. 2014; 27(3):215-20.
215
Introduction
Organ transplantation is the last therapeutic alternative
for patients with certain severe, acute or chronic disease
when there are no other forms of treatment. Transplantation can reverse the clinical picture and aiming to improve the patient’s quality of life.
The process of organ donation involves several
agents and actions on the part of nursing professionals for the care of potential donors. The goal
is to maintain hemodynamics and the viability of
the organ for transplantation. Nurses are also responsible for coordinating the relationship with the
donor’s families, who are experiencing the pain of
losing a family member yet must also decide whether to donate their loved one’s organs.
The actions of health professionals are guided by
codes of professional ethics; however, the decision
making can be based on the needs experienced in
their day-to-day work.(1,2)
Given the many advances in biomedical science
that occurred in the second half of the 20th century,
professional ethical codes are not enough. Organ and
tissues transplantation brought extensive discussions
about the ethics of decision-making with regard to encouraging organ donation and the process for donating
and transplanting organs. (3)
To solve conflicts, ethical analysis of all the related
facts is necessary. Knowledge of the theoretical ethics
that guide and systematize decision-making is also important. Considering this, knowledge of nurses’ ethical
conflicts during the organ and tissues donation process
can contribute to reflections and discussions concerning this topic and help the nursing team to understand
and advise families as they make their decision.
The objective of this study was to determine
nurses’ ethical conflicts on the process for organ and
tissue donation for transplantation and, in the face
of these conflicts, to understand how decisions are
made and what is take into consideration.
Methods
This qualitative study was carried out in a large
hospital in São Paulo, Brazil, to determine the
216
Acta Paul Enferm. 2014; 27(3):215-20.
experience of nurses facing ethical conflicts
during the organ and tissue donation process.
We included 11 nurses who delivered care for
potential donors, for at least one year, at adult
and pediatric critical care units, inpatient units,
emergency departments, and surgical centers
and nurses on the in-hospital committee for organ and tissues donation for transplantation.
The following questions were used to guide
the interviews: “During your professional experience, did any situations pose a conflict of ethics for
you?” “Can you report some ethical conflicts that
you experienced or observed while providing care
of potential organ donors?” “How do you make a
decision in a situation of ethical conflict?” “What
do you consider when you are making a decision?”
Discourses were analyzed using the content
analysis approach proposed by Bardin. Development of this study followed national and international ethical aspects in research on human subjects.
Results
Eleven professionals who experienced ethical conflicts during the organ and tissue donation process
participated in this study. Of these, nine were women and two were men; the age range was 26 to 39
years. The mean time since graduation from college
was eight years. The participants had worked at the
institution for four to 19 years. Most interviewees
worked in adult and pediatric critical care units. The
following categories were identified during analysis
of the interview responses:
Difficulty accepting brain death
Not only physicians and nurses have difficulty accepting brain death; the family members of the potential donors do as well.
The study participants expressed ambiguous feelings when confronted with the care of potential donor:
While they recognized that the death of one patient
can enable the other to continue living, they also were
aware that the potential donor’s heart was still beating
despite brain death and that the person should receive
care in the same manner as if he or she were alive.
Araújo MN, Massarollo MC
The respondents also resisted starting the brain
death protocol because of the difficulty in dealing
with death and the acceptance the brain death; this
behavior is a barrier to proving the diagnosis of
brain death. The same was observed during the interview with family members who showed difficulty
accepting brain death.
Non-acceptance of multidisciplinary team
of withdrawing mechanical ventilation to
non-donor patient after brain death
This category represents a major source of conflict
experienced by nurses when physicians, and nurses
themselves, are reluctant not withdraw mechanical
ventilation for a brain-dead patient who is not an
organ donor.
Although nursing professionals are aware of the
existence of legislation and institutional protocols
to support the removal of mechanical ventilation,
they emphasize the non-acceptance of withdrawing
this measure. The difficulty concerns not only disconnecting the device but also explaining the situation to the family.
For the nurse, removing mechanical ventilation
from someone whose heart is beating, even after the
diagnosis of brain death, generates the impression
that he/she has given up and is “killing” the patient.
Nurses also experience this feeling in situations
when physicians are undecided about removing
the device, and for them it appears that physicians
are deciding whether they will let the patient die
or not, although the patient is already dead. When
nurses recognize that the institutional guidelines
for removing mechanical ventilation in non-donor
patients after brain death must be followed, they
often find a barrier in the form of non-acceptance
by physicians. This situation creates a stalemate between the nurse and physician. It also generates discomfort with regard to keeping a patient who has
already died on artificial support, and postpones
addressing the wishes of the family to receive their
loved one’s body for a funeral.
In addition, nurses report problems with families who do not agree to remove the support from
the patient because they believe that a miracle will
occur and the person will awaken.
Difficulties of multidisciplinary team
during the organ donation process
Difficulties reported by the multidisciplinary team
involve nurses’ conflicts during the organ donation
process. These are related to the medical team’s lack
of knowledge regarding how to carry out the brain
death protocol and the lack of commitment on behalf of the health care professionals. This leads to
negligence and inadequate assistance in caring for
the brain-dead patient.
Nurses reported that the medical team has
doubts about how and when to determine brain
death. This situation generates conflict for family
members because they are informed before the diagnosis and for the nursing team, who, at the conclusion of the brain death protocol, have several
questions that create uncertainty and doubt. This
situation is even worse when there are divergent
opinions among the medical team about the appropriate way to conduct the protocol.
Situations that can interfere in the organ
donation process
The nurses identified the following situations as
presenting ethical conflicts and as interfering in the
organ donation process: religion, lack of communication, difficulties in interpersonal relationships,
and scarcity of human and material resources. Nurses reported that such situations cause indifference,
lack of commitment, and dissatisfaction, which affect the effective deployment of the process.
Decision-making when facing ethical
conflicts
When nurses face ethical conflicts, they often
make decisions based on discussion. They reported that communication and team work are
important aspects in this process, but it was not
clear from what basis the professional assumes a
position regarding the conflict. Concerns about
legislation and the principle of beneficence were
identified when actions performed for the purpose
of benefiting another person were mentioned. In
the case of organ donation and transplantation,
there is greater benefit with an intervention that
saves lives.
Acta Paul Enferm. 2014; 27(3):215-20.
217
Discussion
Ethical conflicts experienced by nurses were structured into five categories. Their experience confirmed what has been described in other studies
with nurses during the organ donation process.
The analysis of results enables us to reflect
on the perceptions of nurses who confront ethical conflicts in practice during the organ donation process. It also can be used to support professionals who seek to improve their actions in
resolving ethical conflicts over organ and tissue
donation for transplantation.
Although the concept of death is related not
only to cardiorespiratory arrest but also to the absence of cerebral and encephalic trunk activity (i.e.,
brain death equals death), several uncertainties exist among health professionals because of the belief
that life exists while the heart is beating. For both
the health care team and families, the maintenance
of potential donors with a beating heart in the critical care unit generates the feeling that the patients
are still alive.
Currently, medical and nursing practice in
the context of continual advances and increased
technological resources results in a battle between
knowledge and cultural pressures. Often, these situations imply changes in values about life, generating
insecurity among professionals and repercussions
for the patient.
This reality indicates that society is still changing its perceptions about life and is still trying to
understand the definition of death. Changes to culture and human values require time for the creation
of new conceptions and experiences. Previous studies agree with these assumptions, having found that
most of the studied populations did not accept brain
death as death.(4-10) In Brazil, the diagnosis of brain
death in patients with clinical signs of brain death
is confirmed by two clinical exams and one complementary test, which are part of care delivery for
patient and their families. A major conflict reported
by the nurses in our study concerns withdrawing
therapeutic support for non-donor patients with a
diagnosis of brain death. The justification of withdrawal would be to avoid additional costs and avoid
218
Acta Paul Enferm. 2014; 27(3):215-20.
prolonging the suffering of families. Despite knowledge of the existence of legislation and institutional protocols that support the disconnection of the
ventilator, professionals emphasize non-acceptance
for several reasons, such as the respect for personal,
cultural, and social values; concern about creating
conflicts with families who would not accept organ
donation; concern regarding legal problems; lack of
societal preparation to understand the procedure;
and family members’ belief that the patient’s clinical
course could reverse. Other studies agree with this
affirmation and show that health care professionals have difficulty accepting the diagnosis of brain
death as death and, consequently, do not accept
withdrawal of life support after this diagnosis.(11,12)
Removing life support might cause discomfort
because the individual appears to be alive through
artificial maintenance.(13) However, criteria for
brain death seem to be accepted; there is little resistance to removal of the organs for transplant but
rather to the withdrawing of devices. This contradiction leads to beliefs that brain death is usually
considered only for transplantation, when, in fact,
it means death, independent of whether or not the
organs will be used. The beating heart affects the
performance of the procedure, and this difficulty
increases when there are conflicts between medical
team and family members, or when personal values
and religion are involved.(13,14)
Difficulties reported by multidisciplinary teams
during the organ donation process, such as lack of
knowledge, negligence, and lack of commitment
and professionalism, confirmed the results of earlier studies.(15-17) In general, research reveals that lack
of knowledge about the organ donation process has
a negative impact on attitudes toward organ donation, even among health professionals, which can
lead to not identifying potential donors and not
performing the brain death protocol, identified in
practice by actions of professionals involved.(4-6,8)
Nurses perceived religion, lack of communication, and scarcity of human and material resources
as situations that could interfere in the process of
organs donation.
Religion is an important factor in decision-making in many areas. A study on religion and organ
Araújo MN, Massarollo MC
and tissue donation highlighted that any religion is
absolutely opposed to organ donation; however, the
degree of understanding about religions concerning
the moment of death is diverse.(18) Some religions
perform rituals with the body after death, which
constitutes a negative factor for organ donation
authorization.(18) In practice, some families have refused to donate and justify their decisions on the
basis of their religion; the impression is that families
invoke religion in an attempt to ameliorate the difficulty of making the decision.(14)
Other conflicts experienced by nurses, such as
the difficulty with interpersonal relationships and
scarcity of human resources, can trigger disappointment, disrespect, lack of teamwork, and lack of
communication, all of which result in negligence
and poor care for the patient. The nurses in this
study believe that these conflicts pose difficulties
during development of their activities.
To resolve conflicts, an ethical analysis of related
facts is necessary, as is knowledge of the types of
ethical theories to direct and systematize decision
making.(19) However, in nurses’ decision making
we did not identify ethical streams to support their
positions. Nonetheless we did find support for the
notion of beneficence and concern with legislation
regarding brain death, and observed that the nurses
emphasize use of discussion in these situations.
Conclusion
Ethical conflicts experienced by nurses during
the organ donation process were health care professionals’ difficulty accepting brain death as the
death of the individual, non-acceptance of withdrawing mechanical ventilation of the non-donor patient after brain death, lack of knowledge
to perform the brain death protocol, lack of
commitment, negligent care for the potential
donor, scarcity of human and material resources,
religion, and lack of communication.
Collaborations
Araújo MN and Massarollo MCKB contributed to
the conception of the project, critical review to im-
prove the manuscript intellectual content, drafting
of the manuscript and approval of this final version
for publication.
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Original Article
Translation, adaptation and validation
of a self-care scale for type 2
diabetes patients using insulin
Tradução, adaptação e validação de uma escala para o autocuidado
de portadores de diabetes mellitus tipo 2 em uso de insulina
Thaís Santos Guerra Stacciarini1
Ana Emilia Pace2
Keywords
Translating; Self care; Diabetes mellitus,
type 2; Insulin; Validation studies
Descritores
Tradução; Autocuidado; Diabetes
mellitus tipo 2; Insulina; Estudos de
validação
Submitted
January 15, 2014
Accepted
April 29, 2014
Thaís Santos Guerra Stacciarini
Getúlio Guarita street, 130, Uberaba,
MG, Brazil. Zip Code: 38025-180
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400038
Abstract
Objective: Translate, adapt and validate the Appraisal of Self-care Agency Scale-Revised (ASAS-R) for Brazil.
Methods: A descriptive method for adapting measurement instruments was used with 150 diabetes
mellitus patients. The instrument underwent translation, synthesis of independent translations, evaluation
by a committee of judges, back-translation and submittal of back-translation to original authors, semantic
validation, submittal of the adapted version to original authors, and pretesting.
Results: The ASAS-R maintained semantic, cultural and conceptual equivalence. Cronbach’s alpha was 0.74;
the intraclass correlation coefficient for test-retest reliability was 0.81; and interobserver agreement was 0.84.
Conclusion: The Brazilian-Portuguese version maintained conceptual, semantic and cultural validity, as
compared to the original version. In the discriminant validity, there was correlation between capacity for selfcare, depression and perceived health, but not social support. There were significant differences between
groups regarding age, education levels and insulin self-application.
Resumo
Objetivo: Traduzir, adaptar e validar a escala Appraisal of Self Care Agency Scale-Revised (ASAS-R) para o Brasil.
Métodos: Utilizou-se o método descritivo de adaptação de instrumentos de medidas, em 150 portadores de
diabetes mellitus. As etapas foram: tradução, síntese das traduções independentes, avaliação pelo Comitê
de Juízes, retrotradução, submissão das versões retrotraduzidas aos autores da versão original, validação
semântica, submissão da versão adaptada aos autores da versão original e pré-teste.
Resultados: ASAS-R manteve as equivalências semântica, cultural e conceitual. O alfa de Cronbach foi de
0,74, e o coeficiente de correlação intraclasse, no teste e reteste, foi de 0,81, e na análise interobservadores,
de 0,84.
Conclusão: A versão manteve as equivalências conceitual, semântica e cultural. Confirmou-se a correlação
entre os construtos capacidade de autocuidado, depressão e percepção do estado de saúde, exceto apoio
social. Na validade discriminante, observaram-se diferenças significantes entre grupos, quanto à idade,
escolaridade e autoaplicação de insulina.
Hospital de Clínicas, Universidade Federal do Triângulo Mineiro, Uberaba, MG, 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 report.
1
2
Acta Paul Enferm. 2014; 27(3):221-9.
221
Translation, adaptation and validation of a self-care scale for type 2 diabetes patients using insulin
Introduction
The recognition of chronic illnesses, in this case,
of diabetes mellitus (DM), as serious public health
problems(1) demands that different levels of the
public health care system revise existing practices
and implement actions for promoting self-care.
According to Orem’s Self-Care Theory, selfcare is defined as actions initiated and carried
out by individuals in order to maintain their life,
health and well-being; individuals are an active
part of the decision-making process, identifying
their needs, and the actions to be undertaken for
their care.
In this context, it is essential for patients to take
responsibility for home treatment, which is fundamental to controlling glucose levels and preventing
acute and chronic complications. Such treatment
involves behavioral changes in daily activities,(2) especially among patients of advanced age and who
take insulin.(3)
Some requisites for reaching treatment goals
that have been much discussed are knowledge
about DM and development of psychomotor
skills.(2) These requisites promote and facilitate
self-care activity management. However, patients
must also display the ability to commit to/engage
in self-care activities.(4-6)
Self-care agency or power is a complex ability
which is acquired and developed throughout one’s
daily life. It enables a person to discern factors
which must be controlled and treated, decide what
can and must be done, recognize needs, assess personal and environmental resources, and determine,
commit to and carry out self-care actions.
Thus, an individual’s capacity to engage in
self-care has been widely studied to demonstrate
what individual actions can lead to health promotion, well-being and the maintenance and/or
prevention of illnesses and their complications.
(4-6)
Such capacity can be studied regarding its
development or operativity.
Since capacity for self-care is a subjective construct which cannot be observed directly, but only
through its attributes or indicators, it was necessary
to find a measuring scale in the literature that could
222
Acta Paul Enferm. 2014; 27(3):221-9.
evaluate a person’s capacity to engage in self-care activities according to new health care guidelines.
Among the international scales found (The
Exercise of Self-care Agency, The Denyes Selfcare Agency Instrument, The Perception of SelfCare Agency Questionnaire, The Self-as-Carer
Inventory and The Mental Health-Related SelfCare Agency Scale),(4) the Appraisal of Self-care
Agency Scale by Evers was chosen due to its
popularity for use among the DM population,
although it is not specific to this illness, and for
being strongly correlated to other scales that
measure self-efficacy, depression, social support,
health status, health-promoting lifestyle and
self-care management for DM patients, especially among those taking insulin.(4-6) This scale has
been validated in the following countries: Sweden, Denmark, China, Norway, the Netherlands,
the United States, Mexico and Colombia.(4)
This scale was created based on concepts presented in Orem’s Theory of Self-Care Deficit, as
analyzed by the Nursing Development Conference
Group (NDCG). The items on the scale were constructed from the concept of capacity for self-care,
based on enabling traits (10 power components),
which are specific personal capacities for carrying
out self-care activities. It is also based on operational traits, or the patient’s capacity for organizing personal and environmental resources significant for
their self-care.(4,6)
The scale does not mention the dimensions and
does not aim at verifying whether capacity for selfcare is developed, but rather whether it is in operation. The instrument provides a global and nonspecific measurement, and can be applied to groups of
different ages and health conditions. Its objective
is to evaluate capacity for self‑care and measure the
individual’s power to execute productive actions towards self-care.
The revised version was chosen because it presented a better adjustment index, greater reliability and better validation results when compared to
the original version. The changes presented in the
new version were the exclusion of nine items and
the description of three factors not reported in the
original version.
Stacciarini TS, Pace AE
The ASAS-R is answered on a 5-point Likert
scale and comprises 15 items with five possible answer choices each, only one being correct. A scoring
is: totally disagree = 1; disagree = 2; neither disagree
or agree = 3; agree = 4; totally agree = 5. Of the 15
questions, four refer to negative aspects, and their
scores must be inverted for data analysis. The possible scores run from 15 to 75; the closer to 75, the
higher the operational self-care capacity exhibited
by the individual.(6)
We believe that the use of the ASAS-R in Brazil will contribute towards nursing clinical practice
and research on health care, especially regarding
DM patients.
The objective of the present study was to translate, culturally adapt and validate the Appraisal of
Self-care Agency Scale-Revised (ASAS-R) to the
Portuguese language and Brazilian culture.
Methods
A quantitative methodological study which deals
with the process of translating, adapting and validating the ASAS-R scale to the Portuguese language with a group of Brazilians with diabetes mellitus type 2, all taking insulin. The authorized scale
responsible for the translation and validation for
Portuguese language
The study was conducted in three public health
units in a municipality of the state of Minas Gerais,
an important economic center and regional reference in the field of health and education, in the period between November and September 2010.
The translation and adaptation process for
the ASAS-R followed methodological references(7-9) with the following modifications: we submitted a synthesis of the two translations to a
committee of judges before the back-translation
phase and included a semantic validation phase,
in order to detect problems with item comprehension which might not have been noticed after
back-translation and also to assess scale acceptance and comprehension by the target audience.
Thus, the study went through the following phases: translation, synthesis of independent
translations, evaluation by a committee of judges,
back-translation, submitting back-translation to
authors of the original version, semantic validation,
submitting adapted version to the original authors
and pretesting.(7-9)
In the first phase, two bilingual specialists and
native English speakers, residing in Brazil, translated the scale; the first translator was informed of the
study’s objectives and had experience in the health
field, unlike the second translator.
A synthesized version was created based on the
two translations, and together with the original
scale, was submitted to the committee of judges
for an evaluation regarding its semantic, idiomatic, conceptual and cultural equivalence, in order
to guarantee comprehensibility, as well as face and
content validity.
The committee consisted of seven professionals with command of the English language
that work in the fields of diabetes mellitus, selfcare, methodology for adapting measurement instruments and translation. The minimum level
of agreement adopted was 80% in order for a
modification to be accepted.
Once the consensual version was ready, two
American translators residing in Brazil who have
command of the Portuguese language and Brazilian
culture carried out a back-translation into English.
However, they were not informed about the objective of the study, had no experience in the health
care field, and worked independently.
The back-translations were presented to the
authors of the revised original version. After the
authors’ agreement, the consensual version was
submitted to a semantic validity analysis. During
the semantic validation phase, it was submitted to
18 patients with diabetes mellitus, selected based
on convenience. Participants were homogeneously
distributed regarding gender and education level.
There were six participants for every five items of
the ASAS-R.
All participants answered all the items of the
first consensual version. However, every sixth participant also answered an instrument evaluating
text comprehensibility and pertinence, as well as
registering suggestions for every other fifth item on
Acta Paul Enferm. 2014; 27(3):221-9.
223
the scale. The scale was elaborated and the sample
group selected based on methods used by researchers of the DISABKIDS Group.(10)
The pretesting phase was conducted with the
participation of 50 type 2 diabetes mellitus patients
taking insulin, being attended to by the Family
Health Strategy (ESF) unit. The main goals of this
phase were to identify the need for new linguistic
and conceptual adjustments to the scale, estimate
the duration of the interview in minutes and conduct a preliminary analysis of the internal consistency and distribution of the answers.
For analyzing the psychometric properties of
the translated and adapted ASAS-R, 150 type 2 diabetes mellitus patients participated, all taking insulin and attended to by the three Family Health
Strategy units, including those from the pretesting
phase who fulfilled the following inclusion criteria:
both genders; 18 years of age or older; over one year
of having a type 2 diabetes mellitus diagnosis and of
being registered in the ESF; using insulin; and a
demonstrated capacity to answer the questions on
the instrument.
During this phase, the answers to the ASAS-R
were analyzed for frequency distribution, reliability
(internal consistency and product-moment correlation), replicability (test-retest and interobservers)
and validity (convergent and discriminant construct validity).
The internal consistency analysis of the items
was obtained by means of Cronbach’s alpha (α),
with acceptable values between 0.5 and 0.9, since it
is a scale with few items. For analyzing replicability,
the retest was applied to a sample of 30 people, obtained by the statistics program Statistical Package
for the Social Sciences version 16.0, with an interval
of time between interviews of 15 to 20 days. The
first and second interviews were carried out by the
same interviewer and in the same location.
With regard to data collection for the interobserver agreement analysis, it was conducted on the
same day, by different interviewers. The second interviewer was a nurse who received training about
the studied construct, the instrument being validated and the interview method. The convenience
sample comprised 30, and the intraclass correlation
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Acta Paul Enferm. 2014; 27(3):221-9.
coefficient statistical test was used for test and retest
and interobserver agreement.
For the analysis of convergent construct validity, we used the Depressive Cognition Scale (DCS)
by Souza et al(11) (negative correlation), the Social
Support Survey (MOS) by Griep et al(12) (positive
correlation) and the instrument of Perceived Health
Status questionnaire (SF-36) by Ciconelli et al(13)
(positive correlation). The statistical test used was
Pearson’s correlation coefficient.
Regarding discriminant construct validity analysis, the results of comparisons between known
groups were analyzed by means of Student’s t-test.
This was done to test the hypothesis that the greater
the education level and insulin self-application ability, the greater the score on the capacity for self-care
evaluation scale; and the higher the age, the lower
the score obtained the scale.
Scales were applied to participants by the researcher of the present study, individually and
through an interview. The study was developed according to national and international ethical norms
for research with human beings.
Results
The two translated versions of the original
ASAS-R displayed some differences in language.
The version created by the translator who was
informed about the study’s objectives and had
knowledge in the field of health was directed towards the target audience’s culture and knowledge, while the version created by the translator
who was not informed regarding the study’s objectives and had no experience in the health field
was a more literary translation.
The synthesized version submitted for evaluation by the committee of judges was subject to some
modifications regarding word choice, subject-verb
agreement and the conceptual definition of the
term “self-care agency.” The term suggested instead
was “capacity for self-care,” which is better known
in Brazil and other Latin-American countries. This
phase was concerned with preserving the meaning
of the statements in order to ensure they remained
as close as possible to the original version, while also
guaranteeing the measurement’s replicability.
In the semantic validation phase, participants
pointed out their difficulties in understanding the
completion instructions, one of the answer choices and six items on the scale. For a better level of
understanding, researchers evaluated the doubts
and suggestions, and carried out some adjustments
whenever the level of agreement was less than 80%,
while always endeavoring to maintain the meaning
of the original items.
We took measures, such as including an explanatory example in the completion instructions, to minimize random variation and increase measurement precision, substituting the
answer choice “neither agree or disagree” for
“undecided,” finding substitutes for words not
frequently used in daily life, such as: circumstances, adjustments, energy and effectiveness,
and making some terms more colloquial, as displayed in chart 1.
After the suggested modifications were made,
the second consensual version was submitted to the
pretesting phase. In this step, a new modification
was suggested; the interview time for completing
the items was 5 minutes, the preliminary value
of the items’ internal consistency was satisfactory
(Cronbach’s alpha equal to 0.75) and ceiling and
floor effects were observed for items ASAS-R 4, 7,
8, 11, 12 and 14 (more than 15% of the answers
concentrated in the instrument’s lowest or highest
possible scores). Thus, this second consensual version culminated in the adapted ASAS-R version.
Analysis of the ASAS-R’s psychometric properties was carried out with the participation of 150
people, with sociodemographic and clinical characteristics as displayed below in table 1.
In the same manner as in the pretesting phase,
ASAS-R item distribution displayed ceiling or floor
effects on items ASA-R 4, 7, 11, 12 and 14, except
on item 8.
As shown in table 2, we observed correlations with magnitudes varying from moderate
to strong (r=0.31 to r=0.69) between 13 items
on the ASAS-R, with exception of items ASAS-R
2, 9 and 13, which presented weak correlations
(r=-0.18 to r=0.22). Item ASAS-R 13 was negatively correlated to the entire scale, however, its
exclusion was not justifiable, for the alpha was
not significantly altered.
Chart 1. Items which underwent modification in the semantic validation phase
Item
ASAS-R VPC1 *
BEFORE semantic analysis
ASAS-R VPF**
AFTER semantic analysis
Instructions
Instructions: Mark the best answer for each of the statements Instructions: Mark the best answer for each of the statements below, according
to the scale. Example: Do you agree with item 1? If so, you will say/mark X in
below, according to the scale
the space for “agree or totally agree.” The difference between “agree and totally
agree” is that “totally agree” gives an idea of always and “agree” gives an idea of
most of the time.
Example: I usually sleep enough to feel rested.
Answer: If you are a person who always sleeps enough to feel rested, you will say/
mark “totally agree” for the phrase. However, if you sleep enough to feel rested
most of the time, you will answer “agree.” This example is also relevant for the
choices “totally disagree” and “disagree.”
Answer choices
Neither disagree nor agree
ASAS- R 1
As the circumstances of my life change, I make the necessary As my life changes, I make the necessary changes to stay healthy.
adjustments to stay healthy.
ASAS- R 2
If my physical mobility is decreased, I make the necessary If my ability to move is decreased, I try to find ways to solve this difficulty.
adjustments.
ASAS- R 4
I frequently feel lack of energy to take care of myself as I know I frequently feel lack of enthusiasm to take care of myself as I know I should.
I should.
ASAS- R 8
In the past, I have changed some of my old habits to take better In the past, I have changed some of my old customs to take better care of my
care of my health.
health.
ASAS- R 10
I regularly evaluate the effectiveness of the things I do to stay I regularly evaluate if the things I do to stay healthy are working.
healthy.
ASAS- R 11
In my daily activities, I rarely dedicate any time to care for my In my day-to-day life, I rarely dedicate any time to care for my health.
health.
Undecided
*VPC1-first consensual version for Brazilian Portuguese; **VPF-final version for Brazilian Portuguese
Acta Paul Enferm. 2014; 27(3):221-9.
225
Table 1. Clinical and sociodemographic characteristics, test phase
Clinical and sociodemographic characteristics
n(%)
Variation Interval
Median
Mean
SD
18 - 94
64
58.6
16.4
556.75
Gender
Female
83(55.3)
Male
67(44.7)
Age (years)
<60
56(37.3)
≥60
94(62.7)
Marital Status
Married/living together
72(48.0)
Single
39(26.0)
Widowed
33(22.0)
Divorced/separeted
6(4.0)
Occupation
Retired/pensioner
76(50.7)
Active
48(32.0)
Homemaker
20(13.3)
Unemployed
1(0.7)
Student
5(3.3)
Education Level
Illiterate
17(11.3)
No schooling/can read and write
14(9.3)
1˫9 years of schooling
74(49.4)
≥ 9 years of schooling
45(30.0)
Monthly family income (in minimum monthly wages*)
0 - 2,200.00
1,000.00
924.63
Time with DM (years)
1 - 41
13
10.5
8.78
Time of insulin use (years)
1 - 40
5
6.41
6.24
*value of monthly minimum wage at the time was 545.00 Brazilian reais; SD – Standard Deviation
Table 2. Item correlation coefficient-total and values of
Cronbach’s alpha (α) for the totality of items when each item
was excluded from ASAS-R, test phase
Item correlation
coefficient-total
Cronbach’s Alpha
if item is excluded
ASAS-R 1
0.32
0.71
ASAS-R 2
0.22
0.69
ASAS-R 3
0.32
0.71
ASAS-R 4
0.31
0.70
ASAS-R 5
0.46
0.70
ASAS-R 6
0.32
0.70
ASAS-R 7
0.69
0.66
ASAS-R 8
0.35
0.71
ASAS-R 9
0.19
0.73
ASAS-R 10
0.35
0.71
ASAS-R 11
0.41
0.70
ASAS-R 12
0.51
0.70
ASAS-R 13
-0.18
0.76
ASAS-R 14
0.54
0.69
ASAS-R 15
0.44
0.70
Item
ASAS-R
(α = 0,74)
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Acta Paul Enferm. 2014; 27(3):221-9.
The items’ internal consistency, obtained by
Cronbach’s alpha, was 0.74. The values for the alpha of the totality of items suffered small alterations
when each of the 15 items was excluded (Table 2).
The replicability of the adapted scale, through
test-retest and interobserver reliability analysis, confirmed ASAS-R’s stability (r=0.81; p<0.001) and
equivalence (r=0.84; p<0.001).
Analysis of convergent validity confirmed
the hypothesis of inverse correlation between
ASAS-R and DCS scores (r =-0.70; p<0.001). It
also confirmed our hypothesis of positive correlation with the following domains of the Perceived Health Status instrument (physical and
social aspects were excluded): functional capacity
(r=0.38; p<0.01), vitality (r=0.49; p<0.01), emotional aspects (r=0.36; p<0.01), mental health
(r=0.41; p<0.01) and general state of health
(r=0.52; p<0.01).
On the other hand, the hypothesis of positive
correlation with the Social Support Scale (r=0.12;
p 0.17) was not supported. It is important to highlight that 98% of the interviewees reported living
with family members or other companions.
Regarding discriminant construct validity, the
group of patients with over nine years of schooling
obtained higher scores for capacity for self-care than
did the group with under 9 years of schooling (p
0.002); patients over 75 years old displayed lower
scores on capacity for self-care when compared to
those under 75 (p 0.026); and patients who self-apply insulin obtained higher scores on capacity for
self-care compared to those who do not (p<0.001).
Discussion
Throughout the various phases of the translation
and cultural adaptation process, we observed
that the translator’s profiles resulted in differing
word choices.
Thus, since the items’ cultural and semantic
equivalence would be prioritized in other phases,
such as in the assessment by the committee of judges and semantic validation, we thought it pertinent
to preserve the grammatical structure of the version
closest to the original in its literary form, always observing and comparing the discrepancies and ambiguities between versions.
At the end of this process, the adapted
ASAS-R was analyzed for its reliability, replicability and validation using a group of 150 type
2 diabetes mellitus patients taking insulin. The
number of participants was according to the recommended number in traditional psychometrics, which prescribes a minimum of five and a
maximum of 10 respondents for each item on
the instrument.(9)
The items on the ASAS-R which presented
ceiling or floor effects in the testing phase were: “I
often lack the energy to take care of myself in the
way that I know I should” (ASAS-R 4); “If I take
a new medication, I obtain information about the
side effects to better care for myself ” (ASAS-R 7);
and “I am able to get the information I need, when
my health is threatened” (ASAS-R 12). The answer
choices on the other extreme of “totally disagree”
were: “In my daily activities, I seldom take time to
care for myself.” (ASAS-R 11); and “I seldom have
time for myself ” (ASAS-R 14).
This effect may have been influenced by: the
sociodemographic characteristics of the sample,
who were mostly elderly patients (62.7%) and retirees (50.7%) who had received less than 9 years of
schooling (70.0%); time available time for self-care,
since most are retired; limited reading comprehension; family participation in the decision-making
process; and the easy access to information provided by the ESF unit’s working methodology. As
an example, it is very likely that a retired person
has plenty of time for self-care, thus they may have
completely agreed with this statement.
In the study by Sousa et al(4) the sample comprised 141 patients with DM taking insulin; the
majority were married women with an average
age of 48 years and a good income. However, in
another of their studies,(6) the sample comprised
629 adults from the population in general; the
majority were married women with an average
age of 35, employed, and with a higher education degree.
Based on our assessment that the characteristics of the studied group might have influenced
the answer distribution, we chose not to exclude
or reformulate such items; however, these effects
might have influenced the results obtained when
analyzing internal consistency and item correlation.
Cronbach’s alpha for internal consistency was 0.74,
lower than in the original revised version (α=0.89).
(6)
The present version presented the highest value
found in all the literature, including studies which
used the original version with 24 items (alpha values ranging from 0.59 to 0.80).(4,6)
Although the values of total item correlation
were lower compared to the original study,(6) most
were moderate to strong in magnitude (r=0.31 to
r=0.69), which makes for satisfactory results, when
considering that the ideal value for initial validation
studies must be higher than 0.30.(14)
Regarding the modes of reliability assessment
for the ASAS-R, test-retest and interobserver
analysis were used. The results pointed to strong
correlations of the analyses (r=0.81; p<0.001) e
(r=0.84; p<0.001), respectively, suggesting that
the adapted scale is reliable, for its properties are
stable and equivalent.
Acta Paul Enferm. 2014; 27(3):221-9.
227
Among the scales used for measuring convergent validity,(4-6) we selected the versions which had
already been adapted for Brazil, such as the Social
Support Scale and the Depressive Cognition Scale.
The Perceived Health Status instrument was used
by other studies that used the original ASAS version
with 24 items.
Regarding convergent validity, the hypothesis
of a correlation between capacity for self-care and
social support (r=0.12; p 0.17) was not supported,
despite knowing that the environmental factor “social support” influences an individual’s capacity for
self-care(4,5) and is a strategy for increasing one’s engagement with self-care.(12) One variable that might
have influenced this result was patients’ heightened
perception about their access to emotional, affective
and material support (98% of interviewees do not
live alone).
On the other hand, there was correlation between ASAS-R and DCS scores(r=-0.70; p<0.001)
and also SF-36 scores. The personal factor “depression” can affect an individual’s capacity for selfcare and adequate health-promotion behaviors for
preventing illness and engaging in self-care management, especially in the case of DM. It is one of
the causes of treatment abandonment and, consequently, results in worsened glycemic control and
increased risk of complications.(11)
The correlation between capacity for self-care
and perceived health was observed in the domains of
functional capacity, physical and emotional aspects,
pain, vitality and general state of health. There was
no significant correlation between the social aspect
domain and the total ASAS-R score.
Regarding discriminant construct validity
among distinct groups, statistically significant
differences between age, education level and insulin self-application ability were observed. We
based our hypotheses on Orem’s theoretical references, which state that intrinsic and extrinsic
factors of basic conditioning, including age, education level and use of daily life resources to
carry out activities, affect the development and
maintenance of capacity for self-care.
The hypothesis that capacity for self-care
presents different characteristics among groups
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Acta Paul Enferm. 2014; 27(3):221-9.
of patients who self-apply insulin and those who
do not is justified due to the fact that the evolution of DM, in addition to the senility process,
act in favor of increasing the risk of the appearance of visual, motor and cognitive complications, problems which can interfere in one’s ability for insulin self-application and, consequently, in the capacity for self-care.(3,4,15,16)
In this sense, the process undertaken resulted in a valid, reliable, replicable, comprehensible, brief and easily applicable scale. Thus, the
present study contributes towards the Brazilian
Unified Health System’s proposals for primary health care and health promotion, especially
among DM patients.
More evidence of this scale’s validity must be
gathered in order to increase the confidence surrounding its usage. In addition, the scale should
preferably be applied to general population samples to strengthen the results of the psychometric
analysis and demonstrate the dimensionality of the
factorial structure proposed by the authors of the
original revised version, which was not the objective
of the present study.
Conclusion
The Brazilian-Portuguese version of the ASAS-R,
obtained after translation and adaptation with a
group of insulin-taking type 2 diabetes mellitus
patients, maintained conceptual, semantic and
cultural equivalence, according to the original
version. Regarding convergent validity, we confirmed correlations between capacity for selfcare, depression and perceived health, but not
social support. In terms of discriminant validity, we observed significant differences between
groups regarding age, education levels and insulin self-application.
Collaborations
Stacciarini TSG created the project, executed the
research and wrote the article. Pace AE provided
relevant critical reviews of intellectual content and
obtained final approval for publication.
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Original Article
Quality of life related to the health of
chronic renal failure patients on dialysis
Qualidade de vida relacionada à saúde de
pacientes renais crônicos em diálise
Jéssica Maria Lopes1
Raiana Lídice Mor Fukushima1
Keika Inouye1
Sofia Cristina Iost Pavarini1
Fabiana de Souza Orlandi1
Keywords
Renal dialysis; Nursing assessment;
Chronic renal failure; Quality of life
Descritores
Diálise renal; Avaliação em
enfermagem; Qualidade de vida;
Insuficiência renal crônica
Submitted
December 19, 2013
Accepted
May 5, 2014
Abstract
Objective: To assess the quality of life related to the health of chronic renal failure patients on dialysis.
Methods: Cross-sectional study with 101 chronic renal failure patients who had been under dialysis treatment
for three months. The instruments used for research were: Instrument of Characterization of Subjects and the
Kidney Disease Quality of Life-Short Form. A descriptive analysis was performed and the standard deviation
was found; Cronbach’s alpha was used to assess the reliability of alpha values equal to or greater than 0.60.
Results: The quality of life was proven to be compromised in the following aspects: “Physical Function (30.20),
Work Situation (37.13) and Physical Functioning”. The best perceptions were: “Cognitive Function (89.31),
Social Support (88.61) and Sexual Function (84.58)”.
Conclusion: Quality of life related to the health of chronic renal failure patients on dialysis was more
compromised in physical aspects.
Resumo
Objetivo: Avaliar a qualidade de vida relacionada a saúde de pacientes renais crônicos em diálise.
Métodos: Estudo transversal com a inclusão de 101 pacientes renais crônicos com três meses de tratamento
dialítico. Os instrumentos de pesquisa foram: Instrumento de Caracterização dos Sujeitos e do Kidney Disease
Quality of Life- Short Form. Foi realizada análise descritiva e desvio padrão; coeficiente Alfa de Cronbach para
verificar a confiabilidade para valores de alfa iguais ou superiores a 0,60.
Resultados: A qualidade de vida mostrou-se comprometida nos domínios: “Função Física (30,20), Situação
de Trabalho (37,13) e Funcionamento Físico”. As melhores percepções ocorreram: “Função Cognitiva (89,31),
Suporte Social (88,61) e Função Sexual (84,58)”.
Conclusão: A qualidade de vida relacionada a saúde de pacientes renais crônicos em diálise apresentou maior
comprometimento nos domínios físicos.
Fabiana de Souza Orlandi
Washington Luis Highway, km 235,
São Carlos, SP, Brazil.
Zip Code: 13565-905
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400039
230
Acta Paul Enferm. 2014; 27(3):230-6.
Universidade Federal de São Carlos, São Carlos, SP, Brasil.
1
Lopes JM, Fukushima RL, Inouye K, Pavarini SC, Orlandi FS
Introduction
Chronic renal failure is considered to be a public
health issue, and it consists of the slow, gradual
and irreversible loss of renal function, resulting
in failure of the kidneys to perform their basic
functions.(1,2)
The number of patients undergoing dialysis treatment has been growing over the years,
from 42,695 cases in 2000 to 91,314 in 2011,
hemodialysis being the most common form of
treatment.(3)
During the treatment stage, chronic renal failure patients may have their quality of life altered,
as there is anxiety prior to and during treatment,
loss of autonomy, difficulty of dealing with an irreversible and incurable disease, difficulty of going
to a hospital daily or weekly, decrease in vitality
levels, limitations in performing everyday activities, and frequent lack of support from relatives
and friends, all of which damage the patient’s
physical and mental health.(4)
As renal failure develops, patients can show
symptoms that affect their daily life. In more advanced stages, the impact on the functional state
and quality of life becomes very clear. Renal replacement therapies, such as hemodialysis, partially
rectify the symptoms experienced by patients and
result in additional changes to their lifestyle, which
can affect quality of life.(5)
The objective of this study is to assess the quality
of life related to the health of chronic renal failure
patients on dialysis.
Methods
This is a cross-sectional study carried out in a specialized public health service located in the State of
São Paulo, in the southeastern area of Brazil.
The sample was composed of 101 chronic
renal failure patients on hemodialysis, the inclusion criteria being: 1) Aged 18 or over; 2)
Diagnosed with chronic renal failure diagnosis;
3) Being in hemodialysis treatment for at least
3 months.
The research instruments were the Instrument of Characterization of Subjects and the
Kidney Disease Quality of Life-Short Form (KDQOL-SF). The Instrument of Characterization
of Subjects is composed of questions related to
identification, sociodemographic data and clinical conditions. The KDQOL-SF was developed
by the Working Group in 1997 (version 1.3) and
validated in Brazil in 2003. The KDQOL-SF is
applicable to patients under hemodialysis, aiming to measure the QVRS, in order to meet two
essential properties: the assessment of the aspects
that are important to the health condition and
the integration of the information that came
from specific and general domains, allowing for
a thorough analysis. The score procedure is done
through the KDQOL-SF measurement, and
therefore is analyzed separately. Thus, there is
not a unique value that results from the general
assessment of quality of life related to health, but
rather average scores for each aspect. This analysis enables identification of the actual problems
related to patient health and which have an impact on quality of life.(6,7)
The final score of each aspect varies within a
range of 0 to 100, where the higher score reflects
better quality of life.(6)
Data from the KDQOL-SF were transferred
to a review program produced and made available
by the Working Group. The program also has Microsoft Excel® sheets, which automatically recode
all of the data of the items with reverse scores and
calculates the scores by item of each aspect.
Data collected were transferred to a Microsoft Excel® sheet and the analyses were performed with the help of a statistics program: a)
descriptive: frequency tables, with position figures (mean, median, minimum and maximum)
and standard deviation; Cronbach’s alpha: evaluates the internal consistency of the KDQOL-SF.
Reliability is considered good for alpha values
equal to or greater than 0.60.(7)
Acta Paul Enferm. 2014; 27(3):230-6.
231
national and international rules of ethics in human research.
Table 1. Sociodemographic and Clinical features
Variables
n(%)
Gender
Female
32 (32)
Male
69(68)
Age group (yrs)
Results
The sociodemographic features found in this
study are described in table 1. Out of 101 subjects participating in the study, 69 were male and
32 were female. Their age varied from 24 to 88
years; the age group with the greatest percentage of participants was 50 to 59, at 27%. According to the division by age group, 57 were
adults and 44 were elderly. The prevalent ethnic
group was white (n=50). Regarding marital
status, the majority was married (n=56). As for
schooling, most subjects had completed primary
school (n=28).
Table 1 shows that most subjects had wages ranging from 1.1 to 2 times minimum wage
(30.8%) and were Catholics. We see that the most
prevalent basic disease was systemic hypertension
(59.4%). Regarding the use of medicine, 100% of
individuals made use of it.
In table 2, it is observed that the average
age of the studied subjects was 56.4 (±14.44)
years. As for the clinical variables, the average hemodialysis treatment period was 43.15
(±43.24) months. Concerning the laboratory
tests, the average hematocrit and albumin levels were 32.78 (±15.03%) and 3.78 (±0.47g/dl)
respectively.
In table 3, the average scores of quality of life
related to health are described. It was observed
that the aspects that obtained lower scores were:
“Physical Function (30.20), Work Situation
(37.13) and Physical Functioning” (46.68). On
the other hand, the aspects that obtained higher scores were: “Cognitive Function” (89.31),
“Social Support” (88.61) and “Sexual Function”
(84.58).
Regarding the internal consistency of KDQOL-SF, most aspects obtained satisfactory Cronbanch’s alpha scores (≥ 0,60).
232
Acta Paul Enferm. 2014; 27(3):230-6.
18-29
4(4)
30-39
11(11)
40-49
14(14)
50-59
28(27)
60-69
25(25)
70-79
12(12)
80 or over
7(7)
Color of skin
White
50(49.5)
Brown
31(30.7)
Black
20(19.8)
Marital status
Married
56(55.5)
Divorced
16(15.8)
Widowed
13(12.8)
Single
12(12)
Other
4(3.9)
Schooling
None
7(6.9)
Primary education incomplete
21(20.8)
Primary education complete
28(27.7)
Secondary education incomplete
20(19.8)
Secondary education complete
16(16)
Higher education complete
7(6.9)
Higher education incomplete
2(1.9)
Income*
Equal to or lower than 1MW**
25(26.6)
From 1.1 to 2 MW
29(30.8)
From 2.1 to 3 MW
24(25.5)
More than 3 MW
16(17.1)
Religion
Catholic
68(67)
Evangelical
21(22)
Spiritist
3(3)
Jehovah’s Witness
2(2)
None
7(6)
Basic disease
Hypertension
60(59.4)
Type 2 Diabetes mellitus
27(26.7)
Glomerular nefhritis
4(4)
Genetic/hereditary
3(3)
Other
7(6,9)
Use of medicine
Yes
101(100)
No
Total
*Seven subjects were unable to provide their incomes; **MW=Minimum wage
0(0)
101
Table 2. Length of hemodialysis and laboratory exam results
Variable
n
Mean (Sd)**
Median
Minimum
Maximum
Age (years)
101
56.40(14.44)
58.00
24.00
88.00
Time of Hd* (months)
101
43.15(43.24)
36.00
3.00
240.00
Hematocrit (%)
101
32.78(5.03)
33.30
19.20
47.40
Albumin (g/dl)
101
3.78(0.47)
3.80
2.10
6.90
*Hd = Hemodialysis; *Sd = Standard deviation
Table 3. Quality of life related to health
Aspects
Mean (±Sd)**
Median
Variation
Cronbach’s
alpha
Symptoms/problems
76.09(±13.06)
79.17
31-100
0.72
Effects of renal failure
68.01(±14.83)
68.75
31-100
0.60
Disease burden
51.36(±23.13)
50.00
0-100
0.63
Work situation
37.13(±28.68)
50.00
0-100
0.32
Cognitive function
89.31(±13.57)
93.33
47-100
0.60
Quality of social interaction
82.97(±12,45)
86.67
33-93
0.42
Sexual function
84.58(±20.94)
93.75
25-100
0.79
Sleep
66.73(±17.27)
70.00
20-95
0.70
Social support
88.61(±20.13)
100.00
17-700
0.71
Incentive by the dialysis staff
79.83(±22.77)
75.00
0-100
0.76
Satisfação do paciente
66.83(±20.61)
66.67
0-100
-
Patient’s satisfaction
46.68(±31.39)
45.00
10-100
0.60
Physical functioning
30.20(±35.59)
25.00
15-90
0.92
Pain
69.13(±32.43)
80.00
32-88
0.78
General state of health
49.36(±16.70)
45.00
0-100
0.92
Emotional well-being
69.98(±14.08)
72,00
0-100
0.65
Emotional function
74.59(±31.67)
100,00
10-90
0.57
Social function
55.45(±26.01)
62.50
13-54
0.67
Energy/Fatigue
60.50(±18.51)
60.00
25-61
0.74
Discussion
The limitations of the results of this study are associated with the cross-sectional pattern, which
does not allow for the establishment of cause and
effect relationships.
Patients with chronic renal failure under hemodialysis treatment live with an incurable disease that
needs long-term treatment. Besides, the evolution of
the disease and its complications lead to limitations
and changes in their quality of life and that of their
relatives and friends. Out of the 101 studied subjects,
the majority of was male (68%). The Brazilian Society of Nephrology confirmed in the 2011 Census
that approximately 57% of chronic renal failure patients were male, whereas 42% were female.(3)
Observational studies have pointed out the prevalence of the disease in male subjects.(8-11) In other
studies, the prevalence was in female subjects.(12-14)
Regarding the age groups, despite the high percentage of elderly people (42%), the most prevalent age
group was 50 to 59. This finding was also observed
in another study, where the prevalent age group
was 40 to 60.(14) As for the color of skin, white was
prevalent, similar to other studies.(8,10) Concerning
marital status, it was observed that most subjects
were married (55.5%). Similar results were found
in several studies.(8-10,15,16) Regarding religious belief,
most individuals declared themselves as Catholics
(67,0%). This finding conforms to other studies
which reported that the subjects were Catholic in
57% and 85% of cases.(17,18) As for schooling, it was
observed that the prevalence was of subjects who
had completed primary school (27.7%), similar to
other studies in which 63.2% and 56.4% of individuals had the same education level.(6,19)
Concerning income, most subjects had up to
two times the minimum wage (30.8%). In other
studies found in the literature, results were consistent with the present one, as 34% and 46% had a
minimum wage or less.(15,17)
As for clinical features, the prevalence of systemic hypertension was observed (59.4%) as a basic
disease, followed by diabetes mellitus (26.7%). This
finding conforms to the results of another study
that observed that their subjects had diabetes mellitus and hypertension as a basic renal disease in more
than 71% of the total cases.(10)
In this study, the average hemodialysis treatment
time was approximately 43 months (which correActa Paul Enferm. 2014; 27(3):230-6.
233
sponds to 3.6 years). Similar results were found in
the literature, where the average treatment period
was 40 months.(11)
Regarding albumin, the average score of participants was 3.78 (±0.47) g/dl. Albumin is the most
common marker used to evaluate the nutritional
status of hemodialysis patients. The recommended
value for albumin is above 3.5 mg/dl, therefore we
can consider the results of this study within the
normal range.(3,20)
There are publications that found albumin levels above the average (4.11mg/dl and 4.2g/dl, respectively).(11,12) Another clinical variable that was
analyzed was the laboratory test result of hematocrit, used as an anemia marker, which has a reference value of 33%(21) It is worth mentioning that
many studies indicate that anemia affects the quality of life related to the health of chronic renal failure
patients. There is also evidence in the literature that
indicates that hemodialysis patients show significant improvement in their survival when normal
hematocrit is reached.(22)
In our study, the average value of hematocrit
obtained was (32.78%), which is close to the minimum expected value. A research study carried out
in two Spanish hospitals with 53 patients undergoing peritoneal dialysis found an average value of
33.46%.(13) As for the drugs, all participants made
use of them. Another study found an average of 4.1
drugs per day for each hemodialysis patient.(16)
In the assessment of quality of life related to
health, high average scores were obtained in the
aspects “Cognitive Function” (89.31), “Social
Support” (88.61), “Sexual Function” (84.58) and
“Quality of Social Interaction” (82.97). The highest
average score was for “Cognitive Function” (89.31).
Despite having obtained this result, it is worth
mentioning that chronic renal failure patients are
a group at risk for cognitive decline. In that sense,
even with good performance in this aspect, periodic
evaluation of cognitive function is necessary, as there
are many risk factors for cognitive impairment.(23)
The second aspect with the high performance was
“Social Support” (88.61). The importance of social
support to the individual is considerable, as the participation of family in care is an essential resource
234
Acta Paul Enferm. 2014; 27(3):230-6.
for improving better acceptance of the disease and
treatment by patients. Other works also show high
average scores of 79.1, 88.2 and 81.1.(6,13,15) Another aspect that presented high average scores in our
study was “Sexual Function” (84.58), and there are
other studies with similar results.(6,15)
However, a decrease in the levels of quality of
life was observed due to erectile dysfunction, which
is a prevalent condition in chronic renal failure patients. Therefore, the results in this aspect must be
analyzed cautiously, as the sample of patients who
had sexual intercourse up to three weeks before the
test was composed of 30 individuals, which is considered low.(24)
The lowest average scores of quality of life related
to health were: “Physical Function (30.20), Work Situation (37.13) and Physical Functioning” (46.68).
In this context, the results suggest that the set of
symptoms of the diseases, along with the patients’
everyday life factors, have a negative impact on
hemodialysis patients. Worthy of note is that the
“Physical Aspect” may be the most affected in the
perception of these patients.(15)
In our study, the second most affected aspect
was “Work Situation.” Work is a basic condition
for human emancipation and is part of each person’s identity; therefore, it becomes one of the
most precious values of human beings. As a result of the disease and treatment, patients often
need to stop working, and this has an impact on
quality of life. To stop working or to reduce the
workload is an aspect that is opposed to the lifestyle the individual had before, so it has a negative impact on quality of life.(14)
The third aspect with a lower average score
was “Physical Functioning,” showing that there
is a decrease in the ability to perform everyday
activities or work. Some studies have suggested
the implementation of a program of regular
exercise for this group.(25)
Conclusion
Quality of life related to the health of chronic renal
failure patients on dialysis showed a better percep-
tion of the aspects “Cognitive Function,” “Social
Support,” “Sexual Function” and “Quality of Social
Interaction”; and lower scores in “Physical Function,” “Work Situation,” “Physical Functioning”
and “General State of Health”.
Acknowledgments
Research done with the support of the Research Support Foundation of São Paulo (FAPESP, as per its acronym in Portuguese), process number 2012/19453-2.
Collaborations
Lopes JM and Fukushima RLM contributed in
the execution of the research, planning, analysis
and interpretation of data, writing of the article, and final approval of the published version.
Inouye K and Pavarini SCI contributed in the
analysis and interpretation of data, writing of
the article and final approval of the published
version. Orlandi FS participated in the conception of the project, planning, analysis and interpretation of data, writing of the article, critical
review of the content and final approval of the
published version.
8. Bass A, Ahmed SB, Klarenbach S, Culleton B, Hemmelgarn BR,
Manns, B. The impact of nocturnal hemodialysis on sexual function.
BMC Neprol. 2012; 13 (67):13-67.
9. Biavo BM, Tzanno-Martins C, AraujoML, Ribeiro MM, Sachs
A, Uezima CB, Draibe SA, Rodrigues, CI, Barros EJ. Aspectos
nutricionais e epidemiológicos de pacientes com doença renal crônica
submetidos a tratamento hemodialítico no Brasil, 2010. J Bras Nefrol.
2012;34(3):206-15.
10.Bignotto LH, Kallas ME, Djouki RJ, SassamiI MM, Voss GO, Soto CL,
Fratini F, Medeiros FS. Achados eletrocardiográficos em pacientes com
doença renal crônica em hemodiálise. J Bras Nefrol, 2012;34(3):23542.
11. Guerreiro VG, Alvarado OS, Espina MC. Qualidade de vida de pessoas
em hemodiálise crônica: relação com variáveis sociodemográficas,
médico-clínicas e de laboratório. Rev Latinoam Enferm. 2012;20(5):19.
12.Barberato, SH, Bucharles SG, Souza AM, Costantini CO, Constantini
CR, Pecoits-Filho. R. Assiciação entre marcadores de inflamação e
aumento do átrio esquerdo em pacientes em hemodiálise. Arq Bras
Cardiol, 2013;100(2):41-6.
13.Varela L, Vázquez MI, Bolanos L, Alonso, R. Predictores
psicológicos de La calidade de vida relacionada con La salud
em pacientes em tratamiento de diálisis peritoneal. Rev Nefrol.
2011;31(1):97-106.
14. Grasselli CS, Chaves EC, Simao, TP, Botelho, PB, Silva RR. Avaliação da
qualidade de vida dos pacientes submetidos à hemodiálise. Rev Bras
Clin Med. 2012;10(6):503-7.
15.Braga SF, Peixoto, SV, Gomes IC, Acurcio, FA, Andrade EI,
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16. Sgnaolin V, Prado AE, Figueiredo L. Adesão ao tratamento farmacológico
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Original Article
Social and clinical factors causing
mobility limitations in the elderly
Fatores sociais e clínicos que causam
limitação da mobilidade de idosos
Jorge Wilker Bezerra Clares1
Maria Célia de Freitas1
Cíntia Lira Borges1
Keywords
Aged; Mobility limitation; Geriatric
nursing; Nursing in community health;
Primary care nursing
Descritores
Idoso; Limitação da mobilidade;
Enfermagem geriátrica; Enfermagem
em saúde comunitária; Enfermagem de
atenção primária
Submitted
December 20, 2013
Accepted
May 5, 2014
Abstract
Objective: To investigate the association between physical mobility demands and social and clinical variables
of the elderly living in the community.
Methods: This was a cross-sectional study including 52 elderly community residents. The research instrument
was constructed based on the theory of Virginia Henderson. Data were analyzed using descriptive statistics
and the chi-square or Fisher exact test, with a significance level of 0.05.
Results: The mean age was 72.6 (± 8.6) years, 69.2% were female. There was a prevalence of physical
mobility demands, with significant statistical associations with significant statistical associations with social
and clinical variables.
Conclusion: Physical mobility was influenced by social and clinical characteristics of the elderly in the community.
Resumo
Objetivo: Investigar a associação entre demandas na mobilidade física e variáveis sociais e clínicas de idosos
que vivem em comunidade.
Métodos: Estudo transversal com a inclusão de 52 idosos residentes em comunidade. O instrumento de
pesquisa foi construído com base na teooria de Virginia Henderson. Os dados foram analisados através da
estatística descritiva e do teste do Qui-Quadrado ou exato de Fisher, com nível de significância 0,05.
Resultados: A média de idade foi de 72,6 (±8,6) anos, 69,2% eram do sexo feminino. Houve prevalência de
demandas da mobilidade física, com associações estatísticas significativas com as variáveis sociais e clínicas.
Conclusão: A mobilidade física sofre influência das características sociais e clínicas em idosos da comunidade.
Jorge Wilker Bezerra Clares
Paranjana Avenue, 1700, Campus do
Itaperi, Fortaleza, CE, Brazil.
Zip Code: 60740000
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400040
Universidade Estadual do Ceará, Fortaleza, CE, Brazil.
1
Acta Paul Enferm. 2014; 27(3):237-42.
237
Introduction
The aging of the population has drawn attention
to the health conditions of the elderly, since this
phenomenon is accompanied by higher rates of
morbidity.(1) These changes, and their consequent
functional limitations and disabilities, lead to an increased risk for disorders of physical mobility that
can compromise the autonomy and independence
of these subjects.(2)
During the process of physiological aging,
changes such as loss of muscle mass and reduction
in strength and muscle function, joint stiffness and
reduced range of motion, alterations in gait and in
balance may significantly compromise the physical
mobility of the elderly, predisposing them to falls,
pain and functional disability.(3)
It is noteworthy that several risk factors may be
associated with mobility limitations in the elderly,
and these can be individual, social, environmental
and organizational.(4) In the United States, prevalence estimates suggest that physical mobility limitation is a significant problem for many elderly
and is associated with several potentially modifiable
characteristics, such as social situation, health conditions, and lifestyle.(5) In India, about 10% of the
elderly population suffers with mobility limitations,
and lives in a situation of great social vulnerability.(6)
With the aging of the population worldwide,
the production of evidence-based knowledge becomes of fundamental importance, in order to guarantee the sustainability of societies and quality of
life of elderly people.(7) However, there is a shortage
of studies in the Brazilian literature about the relationship between living conditions and health and
the physical mobility of the elderly, demonstrating
that these aspects have received little attention in
the country.
Knowing the different factors that affect physical mobility in this population will help to identify
approaches for the planning of impactful actions,
focusing on local needs, and the implementation of
existing public policies, supporting the prevention
of disability and dependence, and the promotion of
active aging. This fact has raised questions that elucidated the conduct of this research, which aimed
238
Acta Paul Enferm. 2014; 27(3):237-42.
to investigate the association between physical mobility demands and social and clinical variables in
community-dwelling elderly.
Methods
This was a cross-sectional study conducted within
a territory that covered two micro-areas of a Family
Health Center in Fortaleza, in the northeastern region of Brazil, where the health courses of a public
university developed teaching, research and extension activities.
Participants in the research included people 60
years of age or older, of both sexes, who resided in
the previously selected micro-areas, and who were
in physical and mental condition to respond to the
questions. Elderly people who were not found to
be at home after three attempts to visit were excluded. Of the total of 61 elderly residents in these
micro-areas, identified from the registration completed by community health workers, 52 met the
requirements, composing the final sample.
A questionnaire containing closed-ended questions, with its organization and structure based on
the nursing theory of Virginia Henderson, was developed for data collection.(8) In this study, questions related to the need to move and maintain
proper posture were analyzed, according to that
theory, whose issues addressed items relating to the
presence of difficulties in moving, joint stiffness,
pain with movement, engaging in regular physical
activity, risk for falls, and the need for help in order
to move. Social and clinical characteristics studied
were: age, sex, marital status, education, retirement,
family income, presence of comorbidities, medication use, smoking, alcohol consumption and engagement in physical activity.
In relationship to marital status, all those who
reported being single, divorced or widowed were
considered to be without a partner, and those who
mentioned being married or living in a consensual
union, were considered as having a partner. The age
category was divided into three age ranges. With regard to education, those who could only sign their
names were considered illiterate, and those who
Clares JW, Freitas MC, Borges CL
could read and write as literate. The income category had two divisions (up to three times the minimum wage. and more than three times the minimum wage).
Data collection took place at the homes of
the elderly, in the months of May and June of
2011. Results were processed and tabulated using the Statistical Package for the Social Sciences, version 17.0. For data processing, descriptive
statistics, absolute frequency and percentage tables were used. Either the chi-square test or Fisher’s exact test was used for associations between
categorical variables on the occurrence of values
expected below five, in two by two tables. A significance level of 0.05 was adopted.
The study followed the national and international standards of ethics in research involving
human beings.
Results
There were 52 elderly included; their mean age was
72.6 (±8.6) years, ranging between 60 to 92 years. In
table 1, it can be seen that the female gender(69.2%),
elderly without a partner (51.9%), illiterate (88.5%),
retired (69.2%) and those with income up to three
times the minimum wage (96.2%) predominated.
The main demands related to the need to move
and maintain proper posture identified in the elderly were: difficulties in moving, 22 (42.3%);
joint stiffness, 31 (59.6%); pain with movement,
30 (57.7%); no physical activity, 37 (71.1%); risk
for falls, 35 (67.3%). Despite these problems, only
three individuals (5.8%) were using locomotion
aids - cane, and nine (17.3%) recognized the need
for help to move and maintain proper posture.
Regarding clinical characteristics, the most frequent comorbidities were: arterial hypertension, 25
(48.1%); osteoporosis, 18 (34.2%); diabetes, 10
(19.2%); gastritis, 8 (15.4%); and, urinary incontinence, 8 (15.3%). Other diseases were cited with
lower frequencies: rheumatism, arthritis, arthrosis,
depression, heart failure, chronic renal failure, Parkinson’s disease and Alzheimer’s disease.
Associations between physical mobility demands and social and clinical variables of the participants in this study are shown in table 1.
Table 1. Social and clinical variables and demands for the need to move and to maintain proper posture
Variables
n(%)
Difficulties in
moving
Joint stiffness
16(30.8)
36(69.2)
0.018
0.261
20(38.5)
19(36.5)
13(25.0)
0.103
25(48.1)
27(51.9)
p-value*
Risk for falls
Help with
locomotion
0.198
0.030
<0.001
0.046
0.007
0.021
0.273
0.112
0.298
0.122
0.183
0.002
0.037
0.283
0.326
46(88.5)
06(11.5)
0.183
0.021
0.028
0.059
<0.001
0.118
36(69.2)
16(30.8)
0.018
0.261
0.198
0.030
<0.001
0.046
50(96.2)
02(3.8)
0.099
0.236
0.099
<0.001
0.092
0.288
37(71.2)
15(28.8)
0.032
<0.001
0.307
0.069
0.230
0.164
37(71.2)
15(28.8)
0.064
<0.001
0.307
<0.001
0.056
0.465
Pain with movement
Help to move
Gender
Male
Female
Age
60-69
70-79
>80
Marital status
With partner
Without partner
Education
Illiterate
Literate
Retired
Yes
No
Income (in MW**)
Until 3
>3
Morbidity
Yes
No
Medication
Yes
No
Continue...
Acta Paul Enferm. 2014; 27(3):237-42.
239
Continuation
Variables
n(%)
Difficulties in
moving
Joint stiffness
33(63.5)
19(36.5)
0.108
0.012
11(21.2)
41(78.8)
0.058
15(28.8)
37(71.2)
0.032
p-value*
Risk for falls
Help with
locomotion
0.136
<0.001
<0.001
0.318
0.079
0.108
0.253
0.038
0.029
<0.001
<0.001
0.034
0.020
<0.001
Pain with movement
Help to move
Smoking
Yes
No
Alcoholism
Yes
No
Physical Activity
Yes
No
* p-value refers to the chi-square test or Fisher’s exact test; ** The minimum wage (MW) of R$ 545.00 was used, considering the base year, 2011; n = 52
Discussion
The limits of the results of this study refer to
its cross-sectional design, which does not permit
the establishment of relationships of cause and
effect. On the other hand, the implication for
nursing refers to the minimizing of risks to which
the elderly are exposed, through the knowledge
of the factors associated with their limitations in
physical mobility.
The predominance of females in the population
investigated, as expected in relationship to the demographic composition of the elderly, due to the
greater longevity of women, was similar to results
found in other studies.(1,3,9)
The feminization of old age is consistent, in part,
with the prevalence of disorders of mobility among
the elderly. The imbalance of calcium reabsorption,
the constant demineralization of bone mass and
density, which results in higher porosity and fragility of bone tissue, which can cause pain and allow
the occurrence of fractures, with increased risk for
limitations in physical mobility, is observed during
the aging process in women with menopausal estrogen suppression.(10,11)
The females also showed a statistically significant
difference in the risk for falls (p=0.030). Studies indicate that being female is one of the major factors
associated with increased risk for falls.(12) This may
be related to greater loss of bone and muscle mass,
in addition to the multiple tasks that women perform at home, leading them to a greater tendency
of falling.(13)
Age was associated with mobility problems
among the elderly, with statistically significant dif-
240
Acta Paul Enferm. 2014; 27(3):237-42.
ferences in joint stiffness (p=0.007) and pain with
movement (p=0.021), with a prevalence of changes
in the age group above 70 years old. Studies reveal
that mobility limitations are, in part, related to the
normal aging process, due to loss of muscle mass
and bone density and to the articular wear, accentuated beginning at 70 years of age.(5)
Marital status also seemed to have an influence
on mobility limitations. A study conducted in five
European countries (Finland, Netherlands, Germany, Hungary and Italy) found that elderly people
without a partner are more likely to report greater
difficulties related to the need to move.(14)
Relating to education, the illiterate elderly had
higher physical mobility demands. Those with lower instructional levels, associated with unfavorable
socioeconomic and cultural factors, may have difficulty acquiring information and having awareness
about the importance of health care throughout
life, the need for adherence to treatment, and maintenance of healthy lifestyles, indirectly contributing
to the occurrence of mobility disorders.(15)
In this context, family health teams need to develop health promotion actions and prevention of
complications, considering the low economic and
educational levels of the elderly population. Such
actions will need to be appropriate to the socio-cultural universe of this group, increasing the incentive
for self-care.
Retirement was also related to impaired physical mobility in this study. One possible justification
for this relationship corroborated the results of a
population-based study conducted in England with
1,693 workers, aged 50 years or more, which found
that mobility limitations and musculoskeletal pain
Clares JW, Freitas MC, Borges CL
were predictors of early retirement.(16) On the other
hand, the losses resulting from the withdrawal from
work activities, with a reduction in work income,
may be determinants of functional impairment,
manifested by the adoption of sedentary attitudes,
making the person vulnerable to diseases due to an
unhealthy lifestyle,(17) such as mobility problems.
However, the cross-sectional design used in this
study did not allow the establishment of what was
a cause and what was a consequence, between impaired physical mobility and retirement.
The presence of comorbidities may be a risk factor associated with mobility limitations in the elderly, resulting in loss of functional capacity.(5) Thus, it
may explain the high number of elderly people who
have physical mobility demands associated with
health problems.
A majority of the elderly (71.2%) used medications, and this variable was significantly associated
with joint stiffness (p = 0.000) and the risk for falls
(p = 0.000). It is noteworthy that, although not
verifying other statistically significant relationships,
physical mobility demands among the elderly who
were using continuous medications prevailed.
The increase in the use of medications among the
elderly was due to the higher prevalence of chronic
diseases and the sequelae that accompanied advancing age.(18) The more medications the elderly ingest,
the greater the risk of interaction between the medications, in addition to potentiation of their side effects.
Therefore, the medical prescriptions for the elderly
should be made carefully,(19) as well as the observation
of the occurrence of their effects on mobility.
Lifestyle and health behaviors were important
risk factors for mobility limitations. Corroborating
data from this research, studies show that a sedentary
lifestyle, smoking and alcohol consumption were significantly associated with mobility limitations.(4,5)
In the promotion of health, professionals should
develop strategies to encourage the population to
adopt a healthy lifestyle, particularly physical activity. This practice provides increased endurance and
muscle strength, improves balance, prevents the loss
of bone mass, as well as leading to improvements in
self-efficacy, cognitive performance, recent memory,
decrease in depressive symptoms, and an increase
in social networks, contributing, therefore, significantly to the improvement of the quality of life.(20)
Nevertheless, a challenge to incorporate regular
physical activity into the daily lives of the elderly
was demonstrated. National and international studies demonstrate that the proportion of elderly who
practice physical activity remains low, despite recognizing the benefits of this practice and considering it to be a desirable behavior for the maintenance
of good health.(9,21)
Corroborating these data, it is emphasized that
71.2% of the elderly did not perform regular physical activity, which was statistically associated with
all the demands of the need to move and maintain
proper posture, according to the adopted theoretical approach.
The reduction in activities is an indicator of
frailty, contributing to the decline in functional capacity. Thus, the practice of physical activities by
the elderly is of fundamental importance for the
preservation of mobility and, consequently, for the
maintenance of independence and autonomy.
Changes in mobility must be taken into account
during the assessment of health of the elderly, constituting important markers that could subsidize preventive actions of disability and dependency in old age.
Conclusion
The results showed that the physical mobility demands
in community-dwelling elderly suffered a significant
influence of social and clinical characteristics.
Collaborations
Clares JWB; Borges CL and Freitas MC contributed to the design and development of the research,
data interpretation, writing, critical review of the
relevant intellectual content, and final approval of
the version to be published.
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Original Article
Care practices for patient safety
in an intensive care unit
Práticas assistenciais para segurança do paciente
em unidade de terapia intensiva
Taís Pagliuco Barbosa1
Graziella Artuzi Arantes de Oliveira2
Mariana Neves de Araujo Lopes2
Nádia Antonia Aparecida Poletti2
Lúcia Marinilza Beccaria2
Keywords
Nursing care; Nursing service, hospital;
Nursing, practical; Patient safety;
Intensive care unit
Descritores
Cuidados de enfermagem; Serviço
hospitalar de enfermagem;
Enfermagem prática; Segurança do
paciente; Unidade de terapia intensiva
Submitted
January 6, 2014
Accepted
26 May 2014
Abstract
Objective: To investigate good nursing care practices for patient safety in an intensive care unit.
Methods: Descriptive study using a checklist with 19 items on hygiene/comfort, patient identification/falls and
hospital infection. Four hundred fifty records were analyzed through G test of independence with Williams correction.
Results: Altogether, good care practices are delivered with an index above 90%, exception for position
changing, limb restraints kept clean, and ventilator circuit.
Conclusion: Good nursing care practices for patient safety were performed differently based on work shifts.
Resumo
Objetivo: Verificar as boas práticas assistenciais de enfermagem para segurança do paciente em unidade de
terapia intensiva.
Métodos: Pesquisa descritiva, utilizando um checklist com 19 itens sobre higiene/conforto, identificação do
paciente/queda e infecção hospitalar. Foram analisadas 450 verificações por meio do Teste G de independência
com a correção de Williams.
Resultados: Em conjunto, as boas práticas estão sendo realizadas com índice acima de 90%, com exceção
da mudança de decúbito, restrições de membros limpas e circuito do ventilador.
Conclusão: As boas práticas assistenciais de enfermagem para a segurança do paciente foram realizadas,
com diversidade conforme o turno de trabalho.
Taís Pagliuco Barbosa
Brigadeiro Faria Lima Avenue, 5544,
São José do Rio Preto, SP, Brazil.
Zip Code: 15090-000
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400041
Hospital de Base de São José do Rio Preto, São José do Rio Preto, SP, Brazil.
Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brazil.
Conflicts of interest: none to declare.
1
2
Acta Paul Enferm. 2014; 27(3):243-8.
243
Introduction
The essence of intensive care nursing is neither
in the environment nor in the special devices,
but in the decision-making processes based on
the understanding of patients’ physiological and
psychological conditions, with an emphasis on
safe care.(1,2) The occurrence of care-related iatrogenic events endangers patients’ lives and has
gained nurses’ attention in order to ensure minimal risk care.(1) Investigations on safe practices
concern nurses because research still does not
indicate a specific approach to the challenges of
safety in nursing.(3)
Healthcare free from risks and failures is a goal
to be reached by health professionals and a commitment of professional education.(4) It is not different for the nursing team, since errors may occur
that require immediate nursing actions in order to
correct them, a situation that inevitably creates occupational stress.(5) Nurses working over 12.5 consecutive hours are more prone to error, especially
at the end of the work shift and when performing
multiple tasks.(6)
Professionals who work beyond the time period
mentioned are more exposed to the risk of error, and
the longer the shift the greater the number of accidents.(7) In the intensive care unit, where patients’
clinical conditions range between narrow limits of
normality/abnormality, where small organic changes can lead to severe impairment of body functions,
the risk is greater.(2,8) The occurrence of errors is not
only undesirable, but also harmful, thereby the issue of care safety and the context in which care is
delivered is inevitably related to the assessment of
health services.(9)
Nursing work in the intensive care unit is described as stressful, wearing, fatiguing and overloading, especially regarding the working hours and the
environment.(10,11) Patient safety is related to changes
in the work process, i.e., the way humans produce
and reproduce their existence, interfering with the
way that nurses perform their daily work.(3,12) These
professionals aim to organize nursing work and human resources, with the purpose of creating and implementing appropriate conditions for patient care.
244
Acta Paul Enferm. 2014; 27(3):243-8.
Comprehensive care refers to a mode of nursing work organization, in which a worker provides all nursing care to a patient or group of patients; however it does not ensure integration of
nursing work alone, as pointed out by a study at
a teaching hospital of Santa Catarina. Attention
to the complexity of care also requires workers’
participation in care planning, aimed at patient
safety.(9)
Care evaluation is an important tool in the control of work processes in healthcare.(13) In the intensive care unit, the expectation is to ensure the best
result within patients’ clinical conditions and severity, with the lowest possible rates of procedure-related complications.(14,15)
Errors represent a sad healthcare reality with
serious consequences for patients, professionals and hospital organizations. The nursing team
must have a magnified view of patients, their security processes and systems, mainly to guarantee
security and quality of the process under their responsibility, seeking information about the flow
of their activities, about issues with the environment and human resources, as well as knowledge
about medications, medication interactions, etc.,
contributing to the efficient, responsible and safe
accomplishment of nursing care.(15)
Because of the complexity of nursing care, its
evaluation is necessary, since greater attention to
those aspects can prompt care that avoids patient
harm. The aim of the study was to investigate good
nursing care practices for patient safety in intensive
care units (ICUs).
Methods
This was a longitudinal, prospective study seeking
correlation between variables by means of repeated
observations of the same items over a period of time,
based on the extent of subject exposure during events
and segments.(16) The study was performed in a general university hospital northwest of São Paulo, with
800 beds. Data were collected in three ICUs: (1) cardiology, (2) neurology, and (3) general. These units
were divided into surgical and clinical ICUs. The
Barbosa TP, Oliveira GA, Lopes MN, Poletti NA, Beccaria LM
surgical ICU had ten beds for patients for delivery
of intensive postoperative care after major surgery or
due to surgical complications. The clinical ICU also
had ten beds for intensive care delivered to patients
admitted with diagnoses from all specialties.
The sample consisted of 450 observations, 50 assessments performed in each work period. Patients
not allowed to perform the proposed actions during
assessment were excluded. A checklist was used as
an instrument based on quality of care evaluation
through bedside checking of good care practices, validated and completed by the researcher three times a
week on alternate periods (morning/afternoon/evening) by watching the bedside nursing actions related
to patient care, considering the quality indicators.
The instrument consisted of three items: hygiene
and comfort; identification/prevention of falls, and
control/prevention of hospital infection, subdivided
into 19 sub-items: tidy bed, position changing, presence of egg crate mattress, patient sitting in armchair,
side rails elevated and locked, clean limb restraints
without joint circulation restriction, head of the bed
elevated above 30°, ventilator circuit identified with
date of exchange, ambu circuit protected with plastic
bag, date recorded on central catheter dressing and/
or peripheral venous access, IV sets identified with
dates, infusion pumps identified with medication
names, three-way taps protected with “luer-cone”,
urinary catheter properly secured on the thigh, identified bed, identification bracelet on the left arm, ventilator circuit without presence of condensate, urine
collection bag below the bladder level, and individual
bottle to discard urine.
The results were analyzed by G test of independence with Williams correction, which has the same
characteristics of x2. Excel® software was used to correlate data by means of clusters in different subgroups
through percentages and statistical calculations.
The study abided by the national and international
standards of research ethics involving human beings.
Results
In Intensive Care Unit 1: comparing the work shifts
regarding hygiene and comfort, the item with the
highest disagreement was “position changing”..
During morning and evening periods, 32 (64%)
were correct, whereas in the afternoon, only 26
(52%) were correct. Regarding identification, the
item that most differed from one shift to another
was “infusion pumps”. In the morning period, 49
(98%) were identified and only one (2%) was not.
In the afternoon, 47 (94%) were identified and
three (6%) were not. In the evening, 39 (78%) were
identified and 11 (22%) were not.
Concerning control of hospital infection, as for
the item “identified ventilator circuit”, 31 (62%)
were correct in the morning, 42 (84%) in the afternoon, and 46 (92%) in the evening. Regarding the
date of circuit exchange, there was also a significant
difference, because in the morning 42 (84%) were
identified, 48 (96%) in the afternoon and 37 (74%)
in the evening.
In Intensive Care Unit 2: regarding hygiene and
comfort, the item with the highest disagreement
comparing work shifts was “position changing”.
In the morning, 19 (38%) had correct position
change, 17 (34%) in the afternoon, and 15 (30%)
in the evening. Concerning identification, the item
“infusion pumps” proved to be different. In the
morning, 32 (64%) patients had their pumps identified, 41 (82%) in the afternoon, and 35 (71%) in
the evening.
With regard to control of hospital infection, the
item “correct fixation of indwelling catheters” had different results when shifts were compared. In the morning, 41 (82%) catheters were correctly fixed, 40 in the
afternoon (80%), and 30 (60%) in the evening.
In Intensive Care Unit 3: in relation to hygiene
and comfort, “position changing” was also the item
that most differed among work shifts. In the morning, 49 (98%) were correct, 41 in the afternoon
(82%), and 32 (64%) in the evening. With reference to identification, the item “ventilator circuit”
was discrepant. In the morning, 47 (94%) were
identified, 30 in the afternoon (60%) and 22 (44%)
in the evening.
As for control of hospital infection, “correct
fixation of indwelling catheters” was the item with
the highest discrepancy comparing shifts. In the
morning, 41(82%) catheters were correctly fixed,
Acta Paul Enferm. 2014; 27(3):243-8.
245
Table 1. Items observed in patients hospitalized in Intensive Care Units 1, 2 and 3
Variables
ICU 1
ICU 2
Yes(%)
No(%)
Yes(%)
137(91.3)
13(8.6)
90(60)
60(40)
Egg crate mattress
139(92.6)
Patient sitting safely
139(92.6)
ICU 3
No(%)
Yes(%)
No(%)
147(98)
3(2)
130(86.6)
20(13.4)
51(34)
99(66)
122(81.3)
28(18.7)
11(7.3)
145(96.6)
5(3.3)
142(94.6)
8(5.4)
11(7.4)
148(98.6)
2(1.4)
138(92)
12(8)
Hygiene and comfort
Tidy bed
Position change
Identification/fall prevention
Side rails elevated
142(94.6)
8(5.4)
143(95.3)
7(4.7)
139(92.6)
11(7.4)
Clean limb restraints
136(90.6)
14(9.4)
113(75.3)
37(24.7)
90(60)
60(40)
Identified bed
144(96)
6(4)
148(98.6)
2(1.4)
145(96.6)
5(3.4)
Identification bracelet
141(94)
9(6)
124(82.6)
26(17.4)
138(92)
12(8)
Identified infusion pumps
135(90)
15(10)
108(72)
42(28)
141(94)
9(6)
10(6.7)
Control of hospital infection
Head of the bed elevated
141(94)
9(6)
139(92.6)
11(7.4)
140(93.3)
Identified ventilator circuit
119(79.3)
31(20.4)
76(50.6)
74(49.4)
99(66)
51(44)
120(80)
30(20)
128(85.3)
22(14.7)
101(67.3)
49(32.7)
Date of central catheter exchange
127(84.6)
23(15.4)
140(93.3)
10(6.7)
130(86.6)
20(13.4)
Date of IV set exchange
127(84.6)
23(15.4)
146(97.3)
4(2.7)
136(90.6)
14(9.4)
Protected 3-way taps
142(94.6)
8(5.4)
144(96)
6(4)
143(95.3)
7(4.7)
141(94)
9(6)
111(74)
39(26)
125(83.3)
25(16.7)
Protected ambu
Indwelling catheter correctly fixed
Ventilator circuit without condensate
141(94)
9(6)
139(92.6)
11(7.4)
123(82)
27(18)
Urine collection bag below the bladder level
149(99.3)
1(0.7)
149(99.3)
1(0.7)
147(98)
3(2)
Individual bottle to discard urine
150(100)
-(-)
150(100)
-(-)
150(100)
-(-)
Considering the percentage of comparison for 50 patients in each item observed and each shift, with n=50 (100%), according to test G of independence with Williams correlation
40 (80%) in the afternoon, and 30 (60%) in the
evening. Regarding protected ambus, 42 (84%)
were protected in the morning, 30 (60%) in the afternoon, and 29 (58%) in the evening.
Concerning hygiene and comfort, the item
“position change” was the most different among
shifts. In ICU 2, only 51 (34%) had position
change correctly performed, whereas in ICU 3,
there were 122 (81.3%). As for identification,
the item “clean restraints” had the highest difference. In ICU 1, 136 (90.6%) were clean, and in
ICU 3, only 90 (60%).
Regarding control of hospital infection, the
item “identified ventilator circuit” was the most discrepant, especially between ICUs 1 and 2. In ICU
1, 119 (79.3%) were identified, and in ICU 2, 76
(70.6%). Most items observed were correct, which
depicts good results; as for hygiene and comfort,
the item “presence of egg crate mattress” was 139
(92.6%) in ICU 1, 145 (96.6%) in ICU 2, and 142
(94.6%) in the ICU 3.
Regarding identification and fall prevention,
the item “patient sitting in armchair safely” was
correct in 139 (92.6%) cases in ICUs 1 and 3, and
246
Acta Paul Enferm. 2014; 27(3):243-8.
in 148 (98.6%) cases in ICU 2.. In the control
of hospital infection, the item “head of the bed
elevated” stood out as a good practice in all ICUs,
because in ICU 1, 141 (94%) were correct, 139
(92.6%) in ICU 2 and 140 (93.3%) in ICU 3,
demonstrating attention of the nursing team to
pneumonia prevention (Table 1).
Discussion
Comparing the way to work in three shifts in
the ICUs regarding hygiene and comfort, there
was significant difference in the item “position
change”, with relevant significance (p<0.01).
This care practice is important for the patient,
because it minimizes complications mainly associated with mechanical ventilation and skin integrity, therefore it cannot be overlooked. A Brazilian study found that 40% of the professionals
involved in care believed that pressure ulcers
occurred due to patients’ hemodynamic instability and complexity, 27% believed they occurred
due to staff shortage, which directly affected
Barbosa TP, Oliveira GA, Lopes MN, Poletti NA, Beccaria LM
changing of position, and 20% believed they occurred due to incorrect care delivery by the nursing team.(17) Those reasons may be involved with
the findings of this study, since position change
was the care practice with the lowest rates of delivery in all ICUs.
The items “tidy bed” and “presence of egg
crate mattress” to prevent pressure ulcers were
present in the three units for approximately 90%
of patients. This care practice is part of pressure
ulcer prevention, which has implications for patients’ prognosis and outcome and impact on
hospitalization costs, which corroborates a study
that found an increase in the length of hospital
stay by approximately 6% among patients with
pressure ulcers.(18,19)
Regarding patient identification, medications used, and fall prevention, the item “clean,
dry limb restraint without arm and leg circulation restriction” obtained a relatively high level
of significance when the ICUs were compared
(p<0.01). Studies show that nurses, as members
of the multidisciplinary team and leaders of the
nursing team in the ICU, should develop safe
and effective ways to provide care. Thereby, systematic forms contribute to recognition of the
importance of nursing actions at any level of
healthcare.(20)
Most (95%) identifications of patient rooms
were correct. Concerning the use of the identification bracelet with name, hospital number,
mother’s name and date of admission, the rate
was 89%.
With regard to the control of hospital infection,
of the ten items observed, there was disagreement
between units in the identification of ventilator circuit exchange, which was 79%, 51% and 66% in
ICUs 1, 2 and 3, respectively, exposing the need for
greater emphasis on this nursing care activity. Not
exchanging the circuit periodically in patients with
tracheal tubes significantly increases ventilator-associated pneumonia, and the incidence of respiratory
infections by 40%.(21)
In general, it was found that good practices
were delivered, with an index above 80% for 15
items, with the best results obtained in ICU 1.
Irregularities for the 19 items and for the three
shifts were observed. However, a larger number
was evidenced in the evening, which may be related to the stressful environment itself and sleep
changes presented by professionals who work at
night, reflecting on care.(22)
Ensuring the safety of critically ill patients has
been a major challenge for professionals working
in the intensive care unit because patients undergo many procedures each day, and in some of
these activities, errors may occur with the potential to cause harm.(23) As a consequence, hospitals
need to incorporate a policy of risk management
with focus on education, establishing preventive
barriers at all stages of strategic processes, and
identify opportunities to improve care.(22)
This study demonstrated that the only care
performed 100% was the use of an individual
bottle to discard urine. The items performed
90% or more in the three units were: egg crate
mattress, patient sitting, side rails elevated, bed
identification, head of the bed elevated above
30°, three-way taps protected with “luer cone”,
and urine collection bag below the bladder level.
Therefore, nurses should take into account the
risks when planning care, ensuring and supervising the team, particularly in relation to care,
for the improvement of assistance, minimizing
of errors and indiscretions.(24)
Conclusion
Good nursing care practices related to patient safety were delivered in the three units. In an isolated
view, care delivery was different in the shifts. Altogether, significant differences were found between
ICUs. However, position changing, limb restraints
and identification of the mechanical ventilator circuit had the same profile among units, with lower
rates of performance.
Collaborations
Barbosa TP contributed to the project design, research execution and article writing. Oliveira GAA
contributed to data collection. Lopes MNA contribActa Paul Enferm. 2014; 27(3):243-8.
247
12. Silva BM, Lima FR, Farias SF, Campos AC. Jornada de trabalho: fator
que interfere na qualidade da assistência de enfermagem. Texto &
Contexto Enferm. 2008;15(3):442-8.
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equipe de enfermagem em UTI pediátrica: um enfoque na humanização.
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de enfermagem: uma abordagem holística. 8a ed. Rio de Janeiro:
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3. Alves EF. O Cuidador de Enfermagem e o cuidar em uma unidade de
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4. Padilha KG, Kitahara PH, Gonçalves CC, Sanches AL. Ocorrências
iatrogênicas com medicação em unidade de terapia intensiva:
condutas adotadas e sentimentos expressos pelos enfermeiros. Rev
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18. Barbosa TP, Beccaria LM, Pereira RA. Avaliação da experiência de dor
pós-operatória em pacientes de unidade de terapia intensiva. Rev Bras
Ter Intensiva. 2011;23(4):223-7.
5. Dal SG, Barra DC, Paese F, Almeida SR, Rios GC, Marinho MM,
Debétio MG. Processo de enfermagem informatizado: metodologia
para associação da avaliação clínica, diagnósticos, intervenções e
resultados. Rev Esc Enferm USP. 2013;47(1):242-9.
6. Pedreira ML. Práticas de enfermagem baseadas em evidencias para
promover a segurança do paciente. Acta Paul Enferm. 2009;22(N
Spec):880-1.
7. Almeida AC, Neves AL, Souza CL, Garcia JH, Lopes JL, Barros AL.
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complicações relacionadas à equipe, equipamentos e fatores
fisiológicos. Acta Paul Enferm. 2012;25(3):471-6.
8. Rosa MB, Perini E. Erros de medicação: quem foi? Rev Assoc Med
Bras. 2010;49(3):335-41.
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Hamilton JD. The quality in Australian health care study. Med J Aust.
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10. Carvalho VT, Cassiani SHB, Chiericato C, Miasso AI. Erros mais comuns
e fatores de risco na administração de medicamentos em unidades
básicas de saúde. Rev Latinoam Enferm. 2009;7(5):67-75.
11.Simão CM, Caliri MH, Santos CB. Concordância entre enfermeiros
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uted to the project design. Poletti NAA contributed to
data analysis and article writing. Beccaria LM contributed to the project design, article writing, relevant critical review of its intellectual content, and the approval
of the final version to be published.
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13. Chaboyer W, Thalib L, Foster M, Ball C, Richards B. Predictors of
adverse events in patients after discharge from the intensive care unit.
Am J Crit Care. 2008;17(3):255- 63.
19.Zhan C, Miller MR. Excess length of stay, charges, and mortality
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20.Lima LR, Pereira SV, Chianca TC. Diagnósticos de enfermagem de
pacientes pós-cateterismo cardíaco- contribuição de Orem. Rev Bras
Enferm. 2006;59(3):285-90.
21. Beraldo CC, Andrade D. Higiene bucal com clorexidena na prevenção
de pneumonia associada à ventilação mecânica. J Bras Pneumol.
2008;34(9):707-14.
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turnos sobre a saúde e a vida social em funcionários da enfermagem
em um hospital universitário do Estado de São Paulo. Cad Saúde
Pública. 2009;16(2):553-5.
23. Brasil. Ministério da Saúde. Portaria nº 529, de 1º de abril de 2013.
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prt0529_01_04_2013.html.
24.Compromisso com a qualidade hospitalar (CQH) [Internet]. Manual
de indicadores de enfermagem NAGEH. 2a ed. São Paulo: APM/
CREMESP; 2012. [citado 2013 Set 11]. Disponível em: http://www.
cqh.org.br/portal/pag/doc.php?p_ndoc=125.
Original Article
Analysis of blood pressure records at
post-anesthesia recovery room
Análise dos registros da pressão arterial na sala
de recuperação pós-anestésica
Aline Aparecida Souza Cecílio1
Aparecida de Cássia Giani Peniche2
Débora Cristina Silva Popov2
Keywords
Arterial pressure; Operating room
nursing; Perioperative nursing;
Anesthesia recovery period;
Posthanesthesia nursing
Descritores
Pressão arterial; Enfermagem de centro
cirúrgico; Enfermagem perioperatória;
Período de recuperação da anestesia;
Enfermagem em pós-anestésico
Abstract
Objective: To analyze the blood pressure records and their accuracy in the score of the circulation item at the
post-anesthesia recovery room.
Methods: Cross-sectional study of the postoperative records from 23 histories of patients admitted to the
post-anesthesia recovery room after small and medium-sized surgeries. The Aldrete-Kroulik index was used.
Statistical analysis was applied in numerical and percentage terms.
Results: Upon the patients’ admission, 48% of the records for the circulation item were not accurate. At the
patients’ discharge, 39% were assessed imprecisely.
Conclusion: In some cases, the quality of the records and the accuracy of the Aldrete-Kroulik index score for
the circulation item were not observed, compromising patient safety.
Resumo
Submitted
February 7, 2014
Accepted
May 26, 2014
Objetivo: Analisar os registros da pressão arterial e sua acurácia na pontuação do item circulação na sala de
recuperação pós-anestésica.
Métodos: Estudo transversal que incluiu os registros pós-operatórios de 23 prontuários de pacientes admitidos
na sala de recuperação pós-anestésica após cirurgias de pequeno e médio porte. Foi utilizado o índice de
Aldrete e Kroulik. Foi realizada análise estatística numérica e percentual.
Resultados: Na admissão dos pacientes, 48% dos registros do item circulação não mostraram acurácia. Na
avaliação da alta do paciente, 39% deles foram avaliados de forma imprecisa.
Conclusão: Em alguns casos, não foram observadas a qualidade do registro e a acurácia da pontuação do
item circulação do índice de Aldrete e Kroulik, comprometendo a segurança do paciente.
Débora Cristina Silva Popov
Dr. Enéas de Carvalho Aguiar Avenue,
419, São Paulo, SP, Brazil.
Zip Code: 05403-000
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400042
Universidade de Santo Amaro, São Paulo, SP, Brazil.
1
2
Acta Paul Enferm. 2014; 27(3):249-54.
249
Introduction
The first 24 hours of the postoperative period, called
immediate postoperative period, demand attention
from the multiprofessional and nursing teams,
which follow the patients from their entry in the
post-anesthesia recovery room until their discharge
from this unit.(1)
To guarantee patient safety in that period, the
nurses need to perform some care actions until the
vital signs and protective reflexes have been stabilized, guaranteeing the patients’ comprehensive
assessment, according to the surgical procedure,
anesthetic agents and individual risks. They also
need to heed any complications that may occur
in the immediate postoperative period, such as respiratory, cardiovascular and renal complications,
among others.(2)
In 1970, the Aldrete-Kroulik index was developed, submitted to a revision and update in 1995.
This index is used to systemize the observation of
the patients’ physiological conditions and discharge
from the post-anesthesia recovery room.(1)
The Aldrete-Kroulik index assesses the motor, respiratory, circulatory and neurologic activities, with a score ranging from zero to two points
for each parameters, in which zero indicates the
most severe condition, 1 the intermediary condition and 2 that the functions have already
been established. According to the Aldrete-Kroulik index, the patient receives discharge from
the post-anesthesia recovery room and is transferred to the unit of origin when reaching the
total score between 8 and 10 points.(3) It should
be highlighted that the index is one way to assess
the patient, which does not discard the need for
complementary assessments, like pain, temperature, nausea and vomiting for example, among
others.(2,4)
This scenario entails insecurity regarding the
patient’s forwarding to the unit of destination. The
blood pressure assessment may be compromised
and the patient may be subject to complications or
discomfort related to hypo or hypertension.
The difficulty in the application of the Aldrete-Kroulik index is mainly related to the assess-
250
Acta Paul Enferm. 2014; 27(3):249-54.
ment of the circulatory system, as the identification
of the preoperative blood pressure is needed to
obtain the score. Thus, the patient receives score 2
on the circulation item if the blood pressure varies
within 20% of the pre-anesthesia level; 1 if the pressure varies between 20 and 49% of the pre-anesthesia value; and zero if the variation exceeds 50% of
the pre-anesthesia value. The blood pressure needs
to be calculated appropriately and compared with
the preoperative levels.
It is fundamental for the nursing team to know
this information, as the correct application of the
Aldrete-Kroulik index grants safety to transfer the
patient to the unit of destination. The mistaken
completion of this assessment parameter can expose
the patient to risk situations and lead to the worsening of his general status.(3)
This study aimed to analyze the blood pressure
records and their accuracy in scoring the “circulation” item, according to the Aldrete-Kroulik index,
at the post-anesthesia recovery room.
Methods
This cross-sectional study was undertaken at a hospital in the city of São Paulo, State of São Paulo, in
the Southeast of Brazil, considering 23 histories of
patients submitted to small and medium surgeries
between May and July 2013. Patients over 12 years
of age who spent more than 45 minutes at the recovery room were included.
The sample corresponded to 41% of the mean
number of patients admitted to the post-anesthesia recovery room during that period. The
mean number of surgeries at the service was 51
surgeries/month, and the mean number of admissions to the post-anesthesia recovery room 19
patients/month.
The data collection instrument was a questionnaire that verified the patients’ demographic characteristics (sex, previous disease and age, surgical
procedure data), surgical specialty, type of anesthesia, classification of anesthetic risk according to the
American Society of Anesthesiologists (ASA) and
perioperative problems.
Cecílio AA, Peniche AC, Popov DC
Healthy patients without previous diseases
are classified as ASA I; patients with mild systemic disease as ASA II; patients with severe systemic disease as ASA III; patients with intense
systemic disease that represents a constant death
risk as ASA IV; dying patients as ASA V; and
brain-dead patients who are organ donors as
ASA VI.(2)
As perceived, the nursing professional at the
post-anesthesia recovery room has not properly
assessed the parameters of the Aldrete-Kroulik
index, mainly regarding the assessment of the
circulation, which demands a numerical calculation that is rarely used.
The following data were collected from the “circulation” item of the Aldrete-Kroulik index: preoperative blood pressure; blood pressure upon admission to and discharge from the post-anesthesia
recovery room, percentage of variations between
pre- and post-operative pressure levels and score
registered in the patient file.
The data were analyzed to verify the accuracy of the score as well as the register of the Aldrete-Kroulik index. Hence, the percentage variation between the preoperative systolic and diastolic blood pressure was calculated upon admission and the postoperative systolic and diastolic
blood pressure upon the patients’ discharge from
the post-anesthesia recovery room. After identifying these variables, the Aldrete-Kroulik index
was again applied and the precision of the item
scored was analyzed.
The results were analyzed and presented in tables, using numerical and percentage statistics.
The study development complied with the Brazilian and international ethical standards for research involving human beings.
tem, followed by endocrine diseases; 9 (39%)
patients denied the existence of diseases. Four
presented associated cardiovascular and endocrine diseases.
The patients’ mean age was 41.7 years, with
seven patients (31%) over 60 years of age, followed by the adult age range between 30 and 40
years (22%).
Concerning the surgical specialties, 12 (52%)
were related to otorhinolaryngology, seven
(31%) to general surgery, two (9%) to orthopedics, one (4%) to ophthalmology and one (4%)
to dentistry. As regards the anesthetic procedure,
13 (57%) were submitted to balanced general
anesthesia, seven (30%) to spinal and epidural
anesthesia + sedation and three (13%) to block
+ sedation.
What the ASA estimate and risk are concerned, ten patients (43%) were classified as
ASA I, five (22%) as ASA II and three (13%) as
ASA III. In five patients’ files (22%), two classifications were found.
In tables 1 and 2, the variations between the
blood pressure records upon the patient’s admission
and discharge from the post-anesthesia recovery
room are displayed.
In 4% of the files analyzed, no records were
found of the blood pressure upon the patient’s admission to the post-anesthesia recovery room.
Results
Table 2. Variations in blood pressure and records upon
discharge
According to the demographic characteristics indicated in the 23 files selected for this study, 16
(70%) patients were female. As regards previous
diseases, 14 (61%) patients presented a disease,
most of which related to the cardiovascular sys-
Table 1. Variations in blood pressure and records upon
admission
Blood pressure alteration (%)
n(%)
Correct records
>20
11(48)
11
20-49
8(35)
0
>50
3(13)
0
No records
1(4)
-
23(100)
-
Total
Blood pressure alteration (%)
n(%)
Correct records
>20
13(57)
13
20-49
8(35)
0
>50
1(4)
0
No records
1(4)
-
23(100)
-
Total
Acta Paul Enferm. 2014; 27(3):249-54.
251
Discussion
The study was undertaken at a hospital that mostly
performs outpatient surgeries, that is, the patient is
admitted for the surgery and discharged the same
day, after stabilizing from the surgery and anesthesia. The research limits are related to the cross-sectional design, which does not permit the establishment of cause and effect relations.
The study results showed that most (70%)
of the patients admitted to the post-anesthesia
recovery room were female. In a study of 260
histories of patients submitted to small surgeries,
women were also predominant, corresponding to
54.5% of the study sample.(5) The predominance
of the female sex may be related to the type of
care delivered at the study hospital, but this fact
did not interfere in the proposed results and objectives. Studies show that the female population
tends to visit health services more frequently and
are forwarded more frequently for small and medium surgeries than men, mainly elective surgeries, in which the patient seeks the service due to
some specific problem.(5)
Another result found was the number of patients with previous diseases. In this study, cardiovascular diseases were predominant (61%),
followed by endocrine diseases. Systemic arterial
hypertension was the most prevalent previous
disease. In Brazil, today, hypertension is considered one of the main health problems in the
adult and elderly populations, raising healthcare
costs and entailing risks for the accomplishment
of surgical procedures.(6)
The instability of the cardiovascular system
is frequent after surgeries. Therefore, the nursing team needs to heed possible complications in
that period as, if the manifestations are not detected and treated early, the patient may evolve
with a clinical problem, extending the length of
recovery and increasing the chances of postoperative and anesthetic complications.
Systemic arterial hypertension at the post-anesthesia recovery room may be related to pain,
bladder distension and neuromuscular agitation,
among other reasons. In patients with a history
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Acta Paul Enferm. 2014; 27(3):249-54.
of previous cardiac problems, attention is needed
due to complication risks.(2) The nurses’ careful
assessment of vital signs and the patient during
that period should be done and documented,
guaranteeing patient safety.
Another common previous disease among
those classified as endocrine in this study is diabetes mellitus, mainly type 2. The association
between systemic arterial hypertension and diabetes mellitus is a frequent finding in preoperative assessments.(2,7)
The patients’ mean age was 41.7 years. In
this study, most patients (53%) were over 30
years of age and 31% over 60 years of age. In a
study that aimed to classify the recovery room
patients according to the degree of dependence,
the patients’ mean age was 51.57 years. In another study, which investigated the patients’
mean complications at the post-anesthesia recovery room, found that most patients were over 30
years of age (75.67%).(8-10)
At many services, care at the post-anesthesia
recovery room has been focused on young adult
patients. In this study, we found the prevalence
of elderly people, probably due to the increase of
this age range in the Brazilian population, as well
as the greater possibility of specialized healthcare
and treatment resources, like surgeries of different
dimensions for example. This profile arouses reflections about the need to reconsider the care and the
dependence level, mainly in the immediate postoperative period.(11)
The surgical specialties found are related to the
characteristics of the study hospital, which is an
outpatient care hospital. That explains why small
and medium surgeries have been performed, due to
the care in specialty areas like otorhinolaryngology
and ophthalmology.
The most identified anesthesia type was general balanced anesthesia (57%), in which the
drugs are administered through the intravenous
and inhalation route, followed by spinal and
epidural anesthesia (30%) and blocks with sedation (13%). Other studies also found general
anesthesia as the most frequent, like in a study
involving 65 patients for example, which was
Cecílio AA, Peniche AC, Popov DC
aimed at identifying the most prevalent nursing
diagnoses at the post-anesthesia recovery room.
General anesthesia was registered in 86.1% of
the cases, followed by spinal and epidural anesthesia in 7.7%.(12) Lima et al. found that general
anesthesia was the most prevalent in 76.1% of
the anesthetic procedures performed.(9)
The use of general anesthesia comes with a specific patient profile with well-defined needs for the
post-anesthesia recovery room. It is important for
the nurses to recognize the most frequent type of
anesthesia as, thus, they can know the changes related to the drugs involved in the different procedures faster and more easily. In general anesthesia,
changes like a reduced level of awareness, delay to
wake up, nausea, vomiting, agitation, hypothermia,
among others, are common.
According to the ASA classification, most
patients in this study is classified as ASA I, although there were ASA II and III patients as
well. Studies include this classification as an important indicator of the patient’s level of dependence on nursing care and the length of their
stay at the post-anesthesia recovery room. In
the analysis of the patients’ level of dependence
on nursing care at the post-anesthesia recovery
room, a study found that, as the length of the
patient’s stay at the recovery room increases, the
higher his dependence level on nursing care will
be and the higher the ASA classification. This
fact may indicate the need to adapt the available
resources and to train the nurses.(9)
The ASA classification is an important indicator of the patient’s level of severity and of the risk
possibilities during the anesthesia-surgery procedure. Therefore, nurses should be familiar with this
patient assessment support instrument, especially
when considering that patients superior to ASA III
should be submitted to anesthetic procedures at
hospital services with hospitalization.
The results indicated accurate records (11
patients; 48%) upon the patient’s admission,
when the blood pressure differed by up to 20%
from the preoperative level. When observing the
cases of changes between 20 and 50% and superior to 50% of the blood pressure level, however,
we found records that did not correspond to the
patient’s actual situation.
In a study that identified the main nursing
diagnoses at the recovery room, it was shown
that the risk of disequilibrium in the fluid volume was found in 100% of the patients studied, that is, any patient at the post-anesthesia
recovery room is at risk of circulatory instability,
which may be related to a fluid deficit (hemorrhage), dehydration, ineffective volemic replacement, arrhythmias, besides hyper or hypotension
associated with drug use, like the drugs used in
spinal and epidural anesthesia for example.(12)
The incidence of acute pain should also be
considered, responsible for blood pressure increases, especially in the systolic blood pressure.
In a study about complications and nursing interventions at the post-anesthesia recovery room,
pain appeared as a common complication (54%
of the patients studied). The same study found
arterial hypertension in 4.5% of the patients and
hypotension in 3.2% of the cases, besides 6% of
patients with hemorrhages.(2,12)
In another study, it was evidenced that about
64% of the patients submitted to anesthesia present
episodes of systolic blood pressure <90mmHg and
that more than 93% of them develop at least one
episode of systolic blood pressure and mean blood
pressure below 20% of the baseline value.(13)
The results for the patients’ discharge are
similar to the admission results. The records in
the files of all patients are accurate when the
blood pressure change corresponds to up to 20%
(13 patients; 57%). In the other records, however, once again the professional’s records were not
exact (9 patients; 39%).
In addition, the absence of records for the “circulation” item was noteworthy in 4% of the histories for the patients in this study.
The assessment of the results found in this study
was not intended to demonstrate the reasons for
inaccurate Aldrete-Kroulik index registers. Therefore, further research is suggested to identify these
reasons and consider educative measures directed
at the professionals working at the post-anesthesia
recovery room.
Acta Paul Enferm. 2014; 27(3):249-54.
253
The Aldrete-Kroulik index records are used
as a parameter for discharging the patients from
the recovery room, but are not used in isolation.
Other parameters like pain, nausea and vomiting, respiratory pattern, among others, are also
considered. The register of the item “circulation” in particular involves calculations and, as
perceived, accuracy difficulties were observed,
which could be related to this calculation and,
consequently, to its appropriate interpretation.
Another factor to be considered is the characteristic of the post-anesthesia recovery unit, which
is marked by high turnover, which can cause difficulties for records and their appropriateness to
the patient’s actual situation.(9)
This can compromise the quality of care delivery at the post-anesthesia recovery room, ranging
from appropriate records to patient safety, due to
the lack of records and the possibility of enhanced
risks due to the discontinuity of the care.
Conclusion
In some cases, high-quality records and accurate scores
of the “circulation” item in the Aldrete-Kroulik index
were not observed, compromising the patient safety.
Collaborations
Cecílio AAS contributed to the project conception,
analysis and interpretation of the data and writing
of the article. Peniche ACG cooperated with the final approval of the version for publication a. Popov
DCS cooperated with the project conception, writing of the article and relevant critical review of the
intellectual content.
254
Acta Paul Enferm. 2014; 27(3):249-54.
References
1. Barrreto RA, Barros AP. Conhecimento e promoção de assistência
humanizada no centro cirúrgico. Rev SOBECC. 2009;14(1):42-50.
2. Popov DC, Peniche AC. [Nurse interventions and the complications
in the post-anesthesia recovery room]. Rev Esc Enferm USP. 2009;
43(4): 953-61. Portuguese.
3. Reis CT, Martins M, Laguardia J. [Patient safety as a dimension of
the quality of health care – a look at the literature]. Ciênc Saúde
Coletiva. 2013; 18(7): 2029-36. Portuguese.
4. Castro FS, Peniche AC, Mendoza IY, Couto AT. Temperatura
corporal, índice Aldrete e Kroulik e alta do paciente da
Unidade de Recuperação Pós-Anestésica. Rev Esc Enferm USP.
2012;46(4):872-6.
5. Secoli SR, Moraes VC, Peniche AC, Vattimo MF, Duarte YA,
Mendonza IYQ. [Post operative pain: analgesic combinations and
adverse effects]. Rev Esc Enferm USP. 2009; 43(Esp 2):1244-9.
Portuguese.
6.Sociedade Brasileira de Cardiologia/Sociedade Brasileira de
Hipetensão/Sociedade brasileira de Nefrologia. IV Diretrizes brasileiras
de Hipertensão. Arq Bras Cardiol. 2010;95(Supl 1):1-51.
7. Sociedade Brasileira de Diabetes (SBD) Diretrizes da SBV 2009
[Internet]. Disponível em: http://www.diabetes.org.br/publicacoes/
diretrizes-e-posicionamentos.
8. Moro ET, Godoy RC, Goulart AP, Muniz L, Modolo NS. [Main
concerns of patients regarding the most common complications
in the post-anesthetic care unit]. Rev Bras Anestesiol. 2009;
59(6);716-24. Portuguese.
9. Lima LB, Borges D, Costa S, Rabelo ER. Classificação de pacientes
segundo o grau de dependência dos cuidados de enfermagem
e a gravidade em unidade de recuperação pós-anestésica. Rev
Latinoam Enferm. 2010;18(5): 881-7.
10.Santos MR, Silva SHC, Poveda VB. [Hypothermia in patients
undergoing cesarean section]. Rev SOBEC. 2011;16(4):26-30.
Portuguese.
11.Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa
Nacional por amostra de domicílios - PNAD 2004 [Internet].
Disponível em http://www.ibge.gov.br/mtexto/pnadcoment1.htm.
12.Souza TM, Carvalho R, Paldino CM. [Nursing diagnoses,
prognostics and interventions in the post-anesthesia care unit]
Rev Sobec. 2012;17(4):33-47. Portuguese.
13. Bijker JB, van Klei WA, Vergouwe Y, Eleveld DJ, van Wolfswinkel L,
Moons KG, et al. Intraoperative hypotension and 1-year mortality
after noncardiac surgery. Anesthesiology. 2009;111(6):1217-26.
Original Article
Difficulties faced by parents of children
with gastroesophageal reflux disease
Dificuldades enfrentadas pelos pais de crianças
com doença do refluxo gastroesofágico
Jacqueline Andréia Bernardes Leão Cordeiro1
Sacha Martins Gualberto1
Virginia Visconde Brasil1
Grazielle Borges de Oliveira2
Antonio Márcio Teodoro Cordeiro Silva2
Keywords
Child; Gastroesophageal reflux; Family;
Nursing care; Pediatric nursing
Descritores
Criança; Refluxo gastroesofágico;
Família; Cuidados de enfermagem;
Enfermagem pediátrica
Submitted
February 17, 2014
Accepted
May 26, 2014
Abstract
Objective: Identifying the difficulties faced by parents of children with gastroesophageal reflux disease.
Methods: Qualitative study carried out with 16 parents of children with gastroesophageal reflux disease. A
guiding question was used and the interviews were recorded and transcribed.
Results: Eight categories related to the difficulties faced by parents emerged, as follows: frequent vomiting,
pneumonia, cost of treatment, impaired social interaction, weight loss and disturbed sleep pattern, causing
difficulty in adhering to treatment with insufficient guidance.
Conclusion: The difficulties faced by parents of children with gastroesophageal reflux were represented by
categories that can serve as indicators for the quality of provided care.
Resumo
Objetivo: Identificar as dificuldades enfrentadas pelos pais de crianças com doença do refluxo gastroesofágico.
Métodos: Pesquisa qualitativa realizada com 16 familiares de crianças com doença do refluxo gastroesofágico.
Foi utilizada uma questão norteadora, as entrevistas foram gravadas e transcritas. Utilizou-se a técnica de
análise de conteúdo.
Resultados: Emergiram oito categorias relacionadas às dificuldades enfrentadas pelos pais: vômitos
frequentes, pneumonia, custo com tratamento, convívio social prejudicado, perda de peso, padrão de sono
prejudicado, gerando dificuldade na adesão ao tratamento com orientações insuficientes.
Conclusão: As dificuldades enfrentadas pelos pais de crianças com refluxo gastroesofágico foram
representadas por categorias que podem servir de indicadores para a qualidade do cuidado prestado.
Jacqueline Andréia Bernardes Leão
Cordeiro
227 street, 68 block, unnumbered,
Goiânia, GO, Brazil.
Zip Code: 74605-080
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400043
Universidade Federal de Goiás, Goiânia, GO, Brazil.
Pontifícia Universidade Católica de Goiás, Goiânia, GO, Brazil.
1
2
Acta Paul Enferm. 2014; 27(3):255-9.
255
Introduction
The gastroesophageal reflux (GER) is characterized by the involuntary passage of gastric contents into the esophagus and may occur several times during the day in healthy children and
adults, being classified as physiological or pathological. It reaches 7-8% of children and is present in about 50% of children in the first four
months of life.(1)
The reflux is characterized as physiological when presented in the first months of life.
The postprandial regurgitation arises between
birth and the first six months of life, often with
spontaneous resolution until the first year of the
child.(2-4) In this context, conservative strategies
that do not require medication therapy are indicated, since they have several benefits, low cost
and no side effects.(3,5-7)
In addition to vomiting and regurgitation, other
signs and symptoms are present in the gastroesophageal reflux disease, impairing the clinical status of
patients. This clinical impairment may be primary, with some dysfunction in the esophageal-gastric
junction, or secondary, when it results from food
allergy or intestinal obstruction.(2,8,9)
The difficulty of professionals is noticeable
in the daily practice of care to children with
gastroesophageal reflux, in the management of
these patients. Some measures are important to
minimize or avoid the onset of reflux.(2,3,10) In
this aspect, nurses are indispensable caregivers,
and the adherence of parents to treatment is critical in order to reach a successful outcome of the
nursing guidelines.
The relevance of the study for nursing is linked
to ensuring quality of treatment and effectiveness
in child care. It is believed that nurses can make
a difference because of the specificity of the profession, when leaving the reductionist approach
focused on the illness for the biopsychosocial approach, by ensuring relevant guidance and unlimited support to parents or guardians of children
with this condition.
The objectives of this study were to identify the
difficulties faced by parents of children with gastro-
256
Acta Paul Enferm. 2014; 27(3):255-9.
esophageal reflux and develop an educational brochure with relevant guidelines to the topic.
Methods
It is a descriptive study with qualitative analysis,
focused on the subjects’ expression of subjectivity. In qualitative research, results are developed
in a natural situation with an open and flexible
plan and addressing the reality in a complex and
contextualized way.(11,12)
This research was carried out at a large institution in the city of Goiânia, Goiás, west central
region of Brazil. It attends approximately twenty
parents of children with gastroesophageal reflux
per month. The parents or guardians of children
served in the outpatient clinic of Gastroenterology participated in the study. In total, were included 16 parents of children aged between zero
and five years who met the following inclusion
criteria: age over 18 years and being a companion at the time of consultation.
In order to achieve the proposed objectives,
the adopted procedure for data collection were
interviews based on the following guiding question: What are the difficulties you face when caring for a child with gastroesophageal reflux? For
data analysis, the technique of content analysis
was used.(13)
Parents were interviewed and the statements
were filed in a digital recorder, with subsequent
full transcript.
The development of study followed national
Results
Eight categories related to the difficulties faced
by parents of children with gastroesophageal reflux were identified: Frequent vomiting, pneumonia, cost of treatment, impaired social interaction,
weight loss, impaired sleep pattern, difficulty in
treatment adherence and insufficient guidance.
Cordeiro JA, Gualberto SM, Brasil VV, Oliveira GB, Silva AM
Discussion
Limitations of this study are related to qualitative
design that allows the identification of the meanings of phenomena and qualitative characteristics
that make the object of study, without establishing
relations of cause and effect.
The categories related to the difficulties faced
by parents of children with gastroesophageal reflux were: frequent vomiting, pneumonia, cost of
treatment, impaired social interaction, weight loss,
impaired sleep patterns, difficulty in treatment adherence and insufficient guidance.
The presence of vomiting is closely related to the
child’s position, especially in the postprandial period.(9,14) Regarding vomiting, 75% of parents reported difficulty with its management, and in relation
to positioning approximately 20% had problems.
Although nonspecific, vomiting and regurgitation are the most characteristic symptoms of
gastroesophageal reflux.(2,3,15) The high number of
children with these episodes in the first two quarters of life may be a result of early weaning and the
introduction of complementary feeding, since the
offered amount is imposed by the caregiver and not
necessarily controlled by the child.(5,14)
The small gap between meals, the positioning
and handling of the child in the postprandial period may contribute to the presence of gastroesophageal reflux (GER), and in children who are more
sensitive to the presence of gastric contents into
the esophagus, it can trigger symptoms similar to
esophagitis, justifying the suspicion diagnosis of
gastroesophageal reflux.(5,9,16)
According to testimonies, vomiting and/or
regurgitation are present in the lives of these
children, causing anxiety in parents. This fact
requires further approximation of nurses, in an
attempt to minimize this situation with care and
the guidance appropriated to the level of understanding of the family.
Also in relation to vomiting and regurgitation,
pneumonia is the pathology that became common
in the lives of these children. All respondents reported that their children had pneumonia at least
once during treatment.
Gastroesophageal reflux can cause respiratory
disease by two mechanisms: vasovagal response and
tracheal aspiration of gastric contents.(3,10,17) Tracheal aspiration is considered the main risk factor for
the occurrence of recurrent respiratory infections,
asthma attacks and worsening of patients with
chronic lung disease.(3)
The aspiration of gastric contents may occur
especially at night, when the child is lying and
has persistent cough and difficulty breathing.
There should also be a suspect of reflux when
the patient is awakened by asthma-like attacks,
bronchopneumonic processes or sinusitis without evident cause.(2)
Guidance provided by the nurse, such as positioning the child in the elevated left lateral decubitus, not lying down immediately after meals and
not eating fatty or greasy foods can bring benefits
during treatment and avoid various complications
such as pneumonia, sinusitis and frequent hospitalizations, relieving the anguish of the family.(8)
The emotional distress of parents of children
with GER is often related to financial difficulties.
Faced with the impossibility of completely funding
the treatment of the disease, the family feel helpless
and anxious, since they also need to meet domestic and personal needs, which remain in the background. Many times, the high cost of the prescribed
milk, the diet with specific foods, and the costs with
medications hamper adherence to treatment.(14)
Working in the health area requires the training
of professionals, who need technical and scientific
expertise, in addition to sensitiveness to the reality
of the population they work with. Therefore, the
financial difficulties of the families should be taken
into account in the set of actions developed to solve
the problem.
Children with gastroesophageal reflux have
some problems related to feeding that reflect in
their social lives.(2,3,5,13) In this study, it was possible to observe the difficulties of families due to
depriving their children of various foods common to healthy children. Such as occurred with
exposure to certain situations in commemorative
celebrations, visits to relatives and friends, when
children manifested willingness to eat not recActa Paul Enferm. 2014; 27(3):255-9.
257
ommended foods. This social deprivation negatively impacts on the entire family context because the social isolation of the child, therefore,
results in the isolation of parents.(5,18)
Regurgitation, vomiting, functional dysphagia,
acid or bitter taste in the mouth, postprandial discomfort, nausea and abdominal pain are symptoms
that usually affect children with gastroesophageal
reflux disease, leading to significant weight loss.
(2,3,18,19)
Many parents reduce the supply of food
in face of the discomfort felt by their children and
have difficulty in administering sufficient quantities
of food in a timely manner.(5) The resultant digestive
symptoms, which often contribute to functional
impairment, make children inappetent.
Children with gastroesophageal reflux disease
may also develop oral hypersensitivity, hindering
the acceptance of foods of different consistencies
and textures. In this sense, the nurse has an important role with food guidance, such as not offering acid, fatty or forbidden foods like chocolate
and soda, as well as maintaining a fractioned and
preferably pasty diet.(3,16,20)
Other features presented by children with
gastroesophageal reflux are irritability, excessive crying, sleep disorders, hiccups, restlessness
and refusal to eat. These symptoms are routine
reasons for consultations, especially for infants
younger than three months. At this age, 50% of
infants have gastroesophageal reflux, and therefore the coexistence of these findings itself, does
not constitute a causal relationship.(3,5,16)
Experiencing gastroesophageal reflux on a daily basis can mean physical and emotional distress
of both the child, as the caregiver. The discomfort
caused by the symptoms of the disease makes children angry and tearful, requiring extreme dedication and attention of parents to ensure that more severe complications do not occur, such as aspiration
followed by respiratory arrest. In this sense, nurses
need to be alert to provide adequate information
about sleep management and emergency training in
case a more serious event occurs.(3,6,21)
Although gastroesophageal reflux in children is
quite common, this study found there are still great
difficulties in full adherence to the treatment and
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Acta Paul Enferm. 2014; 27(3):255-9.
the provided guidance. This is because adherence is
subject to many factors such as demographic, social
and economic conditions, the nature of the disease,
the treatment characteristics, as well as the relationship of the patient with health professionals.(22)
Thus, the first step of treatment is the proper parental guidance about what is the gastroesophageal
reflux disease, with emphasis on symptoms arising
from inadequate diets and possible complications
resulting from the non-use of prescribed medications. Guidelines should be adapted to the socioeconomic profile of those involved, extending to all
family members, in order to involve them in the
commitment to properly caring for the child.(3)
The diagnosis of pediatric gastroesophageal reflux disease is made by clinical history and tests (endoscopy, radiological contrast examination of the
esophagus, scintigraphy, manometry, 24-hour pH
monitoring, therapeutic test).
The treatment is clinical, with behavioral and
pharmacological measures and, in the case of complications, the surgical endoscopic treatment may
be necessary.
The nursing care should be family-centered, in
close communication between nurses and parents,
keeping them informed throughout the therapeutic
process about possible complications, and especially
the ways to minimize and correct this situation.
Conclusion
The difficulties faced by parents of children with
gastroesophageal reflux disease were represented by
the following categories: frequent vomiting, pneumonia, cost of treatment, impaired social interaction, weight loss, impaired sleep patterns, difficulty
in treatment adherence and insufficient guidance.
Collaborations
Oliveira GB and Gualberto SM contributed to
the project design, execution of the research
and writing of the article. Brasil VV and Silva
AMTC collaborated with the relevant critical revision of the intellectual content. Cordeiro JABL
contributed to the project design and execution
Cordeiro JA, Gualberto SM, Brasil VV, Oliveira GB, Silva AM
of research, writing the article and final approval
of the version to be published.
11.Reynolds J, Kizito J, Ezumah N, Mangesho P, Allen E, Chandler C.
Quality assurance of qualitative research: a review of the discourse.
Health Res Policy Syst. 2011;9:43.
12. Miller WR. Qualitative research findings as evidence: utility in nursing
practice. Clin Nurse Spec. 2010;24(4):191-3.
References
13.Minayo MC. O desafio do conhecimento: pesquisa qualitativa em
saúde. São Paulo: Hucitec; 2007.
1. Ratier JC, Pizzichini E, Pizzichini M. Doença do refluxo gastroesofágico
e hiperresponsividade das vias aéreas: coexistência além da chance?
J Bras Pneumol. 2011;37(5):680-8.
14.Omari T. Gastroesophageal reflux in infants: can a simple left side
positioning strategy help this diagnostic and therapeutic conundrum?
Minerva Pediatr. 2008;60(2):193-200.
2. Koda YK. Refluxo gastroesofágico em pediatria. São Paulo: Editora de
Projetos Médicos; 2007.
15.Federação Brasileira de Gastroenterologia, Sociedade Brasileira
de Endoscopia Digestiva, Colégio Brasileiro de Cirurgia Digestiva,
Sociedade Brasileira de Pneumologia, Associação Brasileira de
Otorrinolaringologia e Cirurgia Cérvico-Facial. Doença do refluxo
gastroesofágico: tratamento não farmacológico. Rev Assoc Med Bras.
2012;58(1):18-24.
3. Rosen R. Gastroesophageal reflux in infants: more than just a
phenomenon. JAMA Pediatr. 2014;168(1):83-9.
4. Farahmand F, Najafi M, Ataee P, Modarresi V, Shahraki T, Rezaei N.
Cow’s milk allergy among children with gastroesophageal reflux
disease. Gut Liver. 2011;5(3):298-301.
5. Teixeira BC, Norton RC, Pena FJ, Camargos PA, Lasmar LM,
Macedo AV. Refluxo gastroesofágico e asma na infância: um
estudo de sua relação através de monitoramento do pH esofágico.
J Pediatr. 2007;8(6):535-40.
6. Kang SK, Kim JK, Ahn SH, Oh JE, Kim JH, Lim DH, Son BK. Relationship
between silent gastroesophageal reflux and food sensitization in
infants and young children with recurrent wheezing. J Korean Med Sci.
2010;25(3):425-8.
7. Corvaglia L, Monari C, Martini S, Aceti A, Faldella G. Pharmacological
therapy of gastroesophageal reflux in preterm infants. Gastroenterol
Res Pract. 2013;2013:714564.
8. Chung EY, Yardley J. Are there risks associated with empiric acid
suppression treatment of infants and children suspected of having
gastroesophageal reflux disease? Hosp Pediatr. 2013;3(1):16-23.
16. Ferreira CT, Carvalho E, Sdepanian VL, Morais MB, Vieira MC, Silva LR.
Gastroesophageal reflux disease: exaggerations, evidence and clinical
practice. J Pediatr (Rio J). 2014;90(2):105-18.
17. Erkan ME, Ozkan A, Yilmaz A, Asik M, Gunes C, Yilmaztekin MZ, Dogan
AS. The scintigraphic findings of gastroesophageal reflux in children is
related to body weight? J Clin Med Res. 2014;6(1):17-20.
18.Hegar B, Satari DH, Sjarif DR, Vandenplas Y. Regurgitation and
gastroesophageal reflux disease in six to nine months old indonesian
infants. Pediatr Gastroenterol Hepatol Nutr. 2013;16(4):240-7.
19.Falconer J. Gastro-oesophageal reflux and gastrooesophageal reflux
disease in infants and children. J Fam Health Care. 2010;20(5):175-7.
20. Acierno SP, Chilcote HC, Edwards TC, Goldin AB. Development of
a quality of life instrument for pediatric gastroesophageal reflux
disease: qualitative interviews. J Pediatr Gastroenterol Nutr.
2010;50(5):486-92.
9. Baker SS, Roach CM, Leonard MS, Baker RD. Infantile gastroesophageal
reflux in a hospital setting. BMC Pediatr. 2008;8:11.
21. Urrego AM, Benítez CA. Caracterización psicológica de las familias de
niños con enfermedad por reflujo gastroesofágico. Revista Gastrohnup.
2011;13(1):4-9.
10. Golski CA, Rome ES, Martin RJ, Frank SH, Worley S, Sun Z, Hibbs AM.
Pediatric specialists’ beliefs about gastroesophageal reflux disease in
premature infants. Pediatrics. 2010;125(1):96-104.
22.Hegar B, Vandenplas Y. Gastroesophageal reflux: natural evolution,
diagnostic approach and treatment. The Turkish Journal of Pediatrics.
2013;55:1-7.
Acta Paul Enferm. 2014; 27(3):255-9.
259
Original Article
Prevalence of burnout syndrome
among resident nurses
Ocorrência da síndrome de Burnout em enfermeiros residentes
Kelly Fernanda Assis Tavares1
Norma Valéria Dantas de Oliveira Souza1
Lolita Dopico da Silva1
Celia Caldeira Fonseca Kestenberg1
Keywords
Occupational health nursing;
Education, nursing, graduate; Burnout,
professional; Occupational health;
Internship and residency
Descritores
Enfermagem do trabalho; Educação
de pós-graduação em enfermagem;
Esgotamento profissional; Saúde do
trabalhador; Internato e residência
Submitted
March 6, 2014
Accepted
May 26, 2014
Abstract
Objective: To identify the prevalence of burnout syndrome among nursing residents.
Methods: Cross-sectional study with 48 second-year nursing residents. The Maslach Burnout Inventory (MBI)
was used for data collection, as well as a survey with sociodemographic variables.
Results: Ten residents (20.83%) presented alterations in three dimensions of the inventory (Emotional
Exhaustion, Depersonalization and Personal Accomplishment), which indicates a developing burnout syndrome.
Conclusion: The occurrence of burnout syndrome was identified in the group of nursing residents, with the
following determining factors: young and female individuals, single, childless, recently graduated and assigned
to high-complexity sectors.
Resumo
Objetivos: Identificar a ocorrência da síndrome de Burnout em residentes de enfermagem.
Métodos: Estudo transversal com 48 residentes de enfermagem do segundo ano. O instrumento de coleta de
dados foi o Maslach Burnout Inventory e um formulário com as variáveis sociodemográficas.
Resultados: Foram encontrados dez residentes (20,83%) com alterações em três dimensões (Exaustão
Emocional, Despersonalização e Realização Profissional), sugerindo o desenvolvimento da síndrome.
Conclusão: A ocorrência da síndrome de Burnout foi identificada no grupo de residentes de enfermagem, os
quais apresentaram os seguintes fatores determinantes: indivíduos jovens, do gênero feminino, solteiros, sem
filhos, recém-formados e inseridos em setores de alta complexidade.
Norma Valéria Dantas de O. Souza.
28 de Setembro Avenue, 157, Vila
Isabel, RJ, Brazil. Zip Code: 21551030
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400044
260
Acta Paul Enferm. 2014; 27(3):260-5.
Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.
1
Tavares KF, Souza NV, Silva LD, Kestenberg CC
Introduction
Methods
The term “burnout” has been coined to define a
set of symptoms presented mainly by professionals
who work with people – teachers, nurses and doctors, for example –, and who complain of physical
and mental exhaustion, irritability, loss of interest
in work and self-depreciation.
Workers with burnout syndrome find that the
meaning of their relationship with work is lost;
work activities lose their importance; and any effort seems useless. These symptoms indicate an
upcoming collapse, which occurs after all available energy is consumed.(1) In this perspective, it
has been determined that burnout syndrome is
a result of chronic work-related stress, with negative consequences to individual, professional,
family, social and institutional spheres. Workers
lose the ability to (re)adapt to the existing demands of the workplace.(1-3)
Residency programs place recent graduates
into the work market, providing them with an
opportunity to gain professional experience and
become specialists in their chosen area.(3,4) However, we must consider that this professional
may present predisposing factors for developing
physical and emotional fatigue. We must also
consider other characteristics such as age, marital status, idealism, time in the profession, time
in the institution, role conflict and lack of family support, which can increase vulnerability to
burnout syndrome.(4)
Nursing residents practice a profession geared
towards the caring/helping of others. This is also
an element which can lead to intense psychological suffering, for it means dealing with pain, suffering, death and unhappiness, as well as with
the concerns and problems of other human
beings.(2,4)
Given this context, multiple factors act as
possible causes of burnout syndrome among residents. In this light, the guiding question for our
study was: What is the prevalence of burnout
syndrome among resident nurses? Thus, the objective was to identify the prevalence of burnout
syndrome among nursing residents.
A cross-sectional study was carried out in a teaching hospital in Rio de Janeiro, a city located in
the State of Rio de Janeiro, in the Southeast region of Brazil. Data were collected between July
and September of 2011.
The sample population consisted of 48 second-year nursing residents, assigned to the following programs: internal medicine (9), intensive care (7), clinical surgery (6), cardiovascular
(5), nephrology (5), obstetrics (4), pediatrics (3),
adolescent health (3), surgical center (2), psychiatry and mental health (2), neonatology (1)
and worker’s health (1). We chose second-year
nursing students to refrain from inducing the
results towards positively scoring for burnout
syndrome, for people who have less time in their
workplace reality are more pre-disposed to develop the syndrome.
We used the Maslach Burnout Inventory−General Survey for gathering data, as well a survey regarding sociodemographic and work characteristics.
The data were charted on Excel, and logical and
statistical functions were used to qualify and quantify the sociodemographic and work characteristics,
in addition to the three dimensions of burnout syndrome. The results were analyzed in light of a literature review, emphasizing aspects regarding hospital
work organization, burnout syndrome and content
relative to the nursing residency.
Cutoff points were calculated using percentiles and coefficients of variation for each dimension, analogous to the study of the group mentioned above. Thus, for Emotional Exhaustion
we obtained ≥0.68 and ≤0.29 percentiles, which
correspond to 27 and 20 points, respectively; for
Depersonalization, we obtained ≥0.69 and ≤0.21
percentiles, represented by 11 and 3 points, respectively; and for Lack of Personal Accomplishment,
≥0.76 and ≤0.28 percentiles, which correspond to
32 and 24, respectively.
The internal reliability of the instrument was
measured using Cronbach’s alpha, which resulted in
a value of >0.70. In other words, the Maslach Burnout Inventory obtained a coefficient of 0.7694, indiActa Paul Enferm. 2014; 27(3):260-5.
261
cating reliability and good internal consistency. Thus,
the reliability coefficient for the Emotional Exhaustion dimension was 0.8050, for Depersonalization
0.8287, and Personal Accomplishment 0.8227.
The study complied with national and international guidelines for studies involving human
research.
Results
The sample group presented the following sociodemographic characteristics: predominately female
(91.66%), mean age of 26 years (standard deviation
±2.9), single (83.33%), childless (87.50%), from
Rio de Janeiro (52.33%), living with their families
(77.08%), having graduated 1 to 2 years before data
collection (70.83%).
Ten residents (20.83%) displayed alterations in
all three dimensions (Emotional Exhaustion, Depersonalization and Personal Accomplishment), which
are warning signs for the syndrome. This number was
reached by calculating the sum of points obtained on
the responses given by the 48 residents – cutoff points
which did not take into consideration particular sociodemographic and occupational variables.
The residents who presented such alterations
in all three dimensions possessed the following sociodemographic characteristics: individuals with a
mean age of 26 years, in the 23 to 33 age group, all
female, single (90%) and childless (70%). Regarding their origin and place of residence, 80% were
from the state of Rio de Janeiro and 77.77% lived
with their family.
It is also important to emphasize that the nursing residents who presented alterations in all three
dimensions took an average of 1 hour and 12 minutes to commute to work, and 90% had graduated less than three years before the study. In other
words, they were recent graduates.
Regarding the participants that presented such alterations, 60% worked in specialized care units – 20%
in the cardiovascular program and 40% in intensive
care; the remaining residents were distributed among
the surgical center (10%), internal medicine (10%),
nephrology (10%) and obstetrics (10%).
With respect to their work characteristics, 60%
had taken temporary leaves of absence from work
(up to 15 days) due to musculoskeletal disorders,
stress, anxiety, herpes and labyrinthitis, among other
pathologies. It is also significant that some individuals took leaves of absence for more than one disease
and more than once throughout their time as nursing
residents, up to the time of data collection.
Although the number of residents with alterations
in all three dimensions of burnout syndrome is not representative, several individuals presented scores close to
the cutoff points used for classifying dimension alterations. In other words, 43.75% presented the medium-ranged values of Emotional Exhaustion, 37.50%
presented the medium-ranged values of Depersonalization, and 66.6% had low values of Personal Accomplishment (Table 1), which led us to classify them as
pre-disposed to develop the syndrome.
Table 1. Result distribution of Maslach Burnout Inventory (MBI) dimensions
n (%)
Mean points
(SD)
Coefficient
of variation
Minimum
Maximum
High
16(33.33)
24(±7)
0.303
0.29
Medium
21(43.75)
8(±6)
0.746
28(±6)
0.223
MBI dimensions
EE
DE
PA
Low
11(22.91)
High
16(33.33)
Medium
18(37.50)
Low
14(29.16)
High
16(33.33)
Medium
Low
Burnout syndrome
32(66.66)
10(20.83)
SD - standard deviation; EE - Emotional Exhaustion; DE - Depersonalization; PA - Personal Accomplishment
262
Acta Paul Enferm. 2014; 27(3):260-5.
Cronbach’s
Alpha
Cronbach’s
Alpha (MBI)
0.68
0.805
0.7694
0.21
0.69
0.8287
0.28
0.76
0.8227
Cut of point
Upon conducting an individualized analysis of
the cutoff points per variable, we found four other
individuals (8.33%) with altered burnout dimensions scores. Thus, they were classified as being
pre-disposed to develop the syndrome. These individuals possessed similar characteristics to those
who displayed alterations for burnout in all three
dimensions: they lived by themselves or with others; lived in other municipalities; took an average
of 1 hour and 23 minutes to commute to work;
and were assigned to surgical and adolescent health
nursing programs.
Discussion
One limitation of this study was its cross-sectional design, which did not allow us to establish
causal relations. The health of nursing residents
deserves special attention, for we confirmed that
they present vulnerability for mental illness. This
confirmation was based on their profile and the
data obtained in this study, which indicate that the
participants possess characteristics that make them
particularly susceptible to burnout.
These results can lead to relevant points for
teaching-learning institutions and worker health
services to reflect upon, including prevention, detection and practices that minimize burnout syndrome in nursing residents.
In light of the results described, we notice that
there is a parallel with those found in the literature,
which demonstrate that individuals with alterations
indicating possible burnout possess similar susceptibility characteristics. Studies with nursing residents
and physical therapy professionals found individuals who were young, female, single, childless and
at the start of their professional career.(4,5) Another
characteristic which deserves special mention is that,
in addition to carrying out their professional work
activities, residents also accumulate other academic
activities, leading to stress and physical and mental
fatigue. These include academic work, exams, term
papers, and theoretical classes, among others.(5)
Regarding the age group (23 to 33 years), results
show that the group of residents displayed very sin-
gular characteristics. In other words, they were, for
the most part, recent graduates – with 1 or 2 years
since graduation – and inserted in the work market.
In this sense, they were possibly lacking in skills and
practical experience, making them even more insecure or vulnerable to burnout. In this perspective,
limited time of professional experience and young
age can influence their health, for events such as
graduating and entering the work market usually
generate stress. They are new experiences, which
are unfamiliar and can cause fear.(1) Thus, the recent
graduate does not usually have the tools for dealing
with the tensions of the working world. Therefore,
this is a relevant variable for a deeper understanding
of the issue at hand.
Corroborating this analysis, we infer that the
more skills, competence and confidence acquired
with time of professional practice, the higher the
possibility of dealing with stressful situations. In
turn, the chances for developing chronic stress and
burnout syndrome are reduced.(6)
Another noteworthy variable is gender. These
results are very similar to those of other studies conducted with nursing professionals, which demonstrate that women are more inclined to develop
burnout. This profession is represented eminently by
women, and in an androcentric world, women still
suffer from disadvantages, such as taking on other
tiring and stressful unpaid work shifts−, at home
with domestic chores and raising children.(2,7,8)
Studies have demonstrated that marital status
and number of children can act as protective factors for the syndrome.(3) Our results indicate that
the nursing residents who were developing burnout were predominately single and childless, thus
corroborating their susceptibility to the syndrome.
Studies infer that having a partner with whom to
share life and work problems is a significant protective factor against psychological suffering and,
consequently, mental illness.(2,3)
The resident’s place of origin was a relevant
data for analysis, for most out-of-state residents
left their hometowns to specialize in their given
residency program. Thus, it is common for them
to live by themselves or with others throughout
the program. This is a determining factor for reActa Paul Enferm. 2014; 27(3):260-5.
263
duced affective relationships, which corroborates
the possibility of psychological suffering. Furthermore, adapting to other customs and even
different cultures (considering the size of Brazil
and the different colonizing populations) can
lead to stress and burnout vulnerability.(3)
More relevant data is obtained when considering
the specialized units of care chosen by residents. Other studies have also found that the intensive care and
the cardiovascular nursing units present the highest
incidence of residents with the burnout.(4,5) Residency
programs in intensive care units have their particularities, for they involve caring for chronic and/or severely
ill patients, which require specialized techniques and
different types of procedures. Furthermore, more time
availability is required in order to care for the needs
of these patients. On the other hand, residents are
frequently responsible for providing direct care to the
more severely ill patients, which requires a higher set
of skills (psycho-cognitive and motor). Such responsibility can translate into psychological suffering due to
lack of professional experience.(4)
Nonetheless, residents assigned to other work contexts possess characteristics which are equally relevant
to burnout, for they are inserted in a high-complexity teaching hospital, considered a training center of
human resources and technology development in the
health field. This means that residents carry out multiple and refined activities, which requires that the
professional continuously adapt to the characteristics
of this work environment, an exhaustive process of
inner psychological organization and re-organization.
(9)
This can also be considered an important variable
which favors psychosomatic illness and lead to burnout
syndrome.
With respect to the data found on illness-related work leaves, a high percentage of individuals
reported taking leaves of absence. The reasons for
these medical leaves were diseases related to stress
and psychological suffering.(6) Musculoskeletal disorders are diseases caused by physical and mental
overload; oral herpes frequently emerges in stressful
situations, as well as labyrinthitis. Thus, our results
corroborate those found in the literature.(8)
Another important result regards the individuals
with a pre-disposition for developing burnout, who
264
Acta Paul Enferm. 2014; 27(3):260-5.
presented high scores on Emotional Exhaustion, Depersonalization, and low scores on Personal Accomplishment, but who did not make the cutoff score
which characterizes the full syndrome. Nonetheless,
these variations are of significant relevance, for in different circumstances, these individuals can maintain,
reduce or increase their scores in each dimension. This
variance occurs because burnout syndrome involves
multiple factors, both dynamic and multifaceted.(2,9)
Therefore, if the individual who is inclined to develop
the syndrome is transferred to another sector or meets
a partner with whom to share their moments of suffering, these can act as protective factors against burnout,
thus reducing their MBI scores.
However, high Emotional Exhaustion scores can
suggest a syndrome in the making, for it is one of
the initial signs of burnout. This dimension usually
results from overload and personal conflict in interpersonal relationships.(3,5) Emotional Exhaustion is
also a predictor of Depersonalization, which in turn
is a predictor for lower Personal Accomplishment.
Thus, such resident can go from being pre-disposed
to burnout to presenting significant alterations for
developing the full syndrome.
Conclusion
The present study found individuals developing
burnout and uncovered others pre-disposed to the
syndrome among a group of nursing residents. Being young, female, single, childless, and at the start
of a professional career, as well as being assigned to
high-complexity residency programs (cardiovascular and intensive therapy) were found to be predisposing factors for burnout syndrome in a group of
nursing residents.
Acknowledgements
The authors thank the Solução Estatística Júnior
(SEJ) University Outreach Project of Universidade
do Estado do Rio de Janeiro, Rio de Janeiro, Brazil.
Collaborations
Tavares KFA contributed with the study’s conception
and design, data collection, statistical treatment of
data, data analysis and interpretation; drafting of the
article and final approval of the version to be published. Souza NVDO collaborated with the study’s
conception and design, drafting of the article, critical
review for important intellectual content and final approval of the version for publication. Silva LD cooperated with the conception and design, critical revision
of the relevant intellectual content and final approval
of the version to be published. Kestenberg CCF participated in data analysis and interpretation, critical
review for important intellectual content and final approval of the version to be published.
References
1. Franca FM, Ferrari R, Ferrari DC, Alves ED. [Burnout and labour aspects
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syndrome components among nursing personnel]. Texto & Contexto
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3. Silva TL, Benevides-Pereira AM, França IS, Alchieri JC. [Sociodemographic aspcsts related to burnout syndrome in physiotherapists].
Revistainspirar. 2010; 2(1):6-13. Portuguese.
4. Franco GP, Barros AL, Norgueira-Martins LA, Zeitoun SS. [Burnout in
nursing residents]. Rev Esc Enferm USP. 2011; 45(1):12-8.
5. Guido LA, Silva RM, Goulart CT, Bolzan ME, Lopes LF. [Burnout
syndrome in multiprofessional residents of a public university]. Rev Esc
Enferm USP. 2012; 46(6):1477-83. Portuguese.
6. Benevides-Pereira AT, Yamashita D, Takahashi RM. [About the
educators, how are they?]. REMPEC - Ensino, Saúde e Ambiente.
2010; 3(3):151-70. Portuguese.
7. Goulart CT, Silva RM, Bolzan ME, Guido LA. Sociodemographic and
academic profile of multiprofessional residents of a public university].
Rev Rene. 2012; 13(1):178-86. Portuguese.
8. Mauro MY, Paz AF, Mauro CC, Pinheiro MA, Silva VG. [Working
conditions of the nursing team in the patient wards of a university
hospital]. Rev Esc Anna Nery. 2010;14(2):244-52. Portuguese.
9. Ferreira RE, Souza NV, Gonçalves FG, Santos DM, Pôças CR. [Nursing
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Acta Paul Enferm. 2014; 27(3):260-5.
265
Original Article
Compliance with outpatient clinical
treatment of hypertension
Adesão ao tratamento clínico ambulatorial da hipertensão arterial sistêmica
Aurelina Gomes e Martins1
Suzel Regina Ribeiro Chavaglia2
Rosali Isabel Barduchi Ohl3
Igor Monteiro Lima Martins4
Mônica Antar Gamba3
Keywords
Patient compliance; Hypertension/
therapy; Blood pressure monitoring,
ambulatory; Primary care nursing;
Patient acceptance of health care
Descritores
Cooperação do paciente; Hipertensão/
terapia; Monitoração ambulatorial
da pressão arterial; Enfermagem de
atenção primária; Aceitação do paciente
de cuidados de saúde
Submitted
March 13, 2014
Accepted
May 29, 2014
Rosali Isabel Barduchi Ohl
Napoleão de Barros street, 754, São
Paulo, SP, Brazil. Zip Code: 04024-002
[email protected]
Abstract
Objective: Assessing the compliance with outpatient treatment of hypertension.
Methods: Cross-sectional study in which were studied demographic and socioeconomic variables, as well as
of knowledge about the disease. The Morisky-Green Test (MGT) was applied to measure the compliance with
treatment, and multiple logistic regression to identify factors associated with it.
Results: There was homogeneity between compliance/non-compliance regarding gender, age, marital status,
color/race, education, professional activity, number of people in the household and occupation. There was a
significant association between income and compliance with treatment (p = 0.039). The hypertensive subjects
guided by the community health agents had 2.21 times greater risk of non-compliance with medication
compared to those guided by the team and adjustment to income of the subjects non-compliant with
medication (OR = 2.21, CI 1.08 -4, 85, p = 0.033).
Conclusion: Income and the guidance provided by community health agents interfered in the compliance with
treatment, requiring training and the offer of fundraising practices and lifestyle changes.
Resumo
Objetivo: Analisar adesão ao tratamento clínico ambulatorial da hipertensão arterial.
Métodos: Estudo transversal, onde foram estudadas variáveis demográficas, socioeconômicas e de
conhecimento sobre a doença. Aplicou-se Teste de Morisky-Green (TMG) para medir adesão, e regressão
logística múltipla, identificando os fatores associados à adesão.
Resultados: Observou-se homogeneidade entre adesão/não adesão quanto ao sexo, faixa etária, estado
civil, cor/raça, escolaridade, atividade profissional, número de pessoas na casa e ocupação. Evidenciou-se
associação significativa entre renda e adesão ao tratamento (p=0,039). Os hipertensos orientados pelos
agentes comunitários de saúde apresentaram 2,21 vezes mais chance de não adesão à medicação quando
comparados aos orientados pela equipe e ajustados a renda de não/adesão à medicação (OR= 2,21; IC 1,08
-4,85; p=0,033).
Conclusão: A renda e as orientações prestadas pelos agentes comunitários de saúde interferiram na adesão,
havendo necessidade de capacitação e oferecimento de práticas de captação de renda e mudança de hábitos.
Universidade Estadual de Montes Claros, Montes Claros, MG, Brazil.
Escola de Enfermagem, Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brazil.
3
Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
4
Faculdades Integradas Pitágoras de Montes Claros, Montes Claros, MG, Brazil.
1
2
DOI
http://dx.doi.org/10.1590/19820194201400045
266
Acta Paul Enferm. 2014; 27(3):266-72.
Martins AG, Chavaglia SR, Ohl RI, Martins IM, Gamba MA
Introduction
Systemic hypertension is correlated to clinical
complications that lead a significant number of
Brazilians to die. Many complications could have
been avoided and/or minimized, such as acute
myocardial infarction, cerebrovascular accident
and kidney failure, with precocious compliance
with a treatment plan.(1)
The rates are alarming and account for a major cause of death in the country. The mortality
rate from diseases of the circulatory system is increasing every year. Between the years of 2000 and
2011, the number of deaths increased by 28.6%
and in 2011, ischemic heart diseases and cerebrovascular diseases accounted for 61% of deaths in
this category. In addition, cardiovascular diseases are responsible for sequelae and complications
that impair the performance of these citizens in
their own lives, in the lives of their families and
ultimately in society as a whole.(2,3)
Studies indicate that low compliance with
treatment is present in 50% of cases of decompensated hypertensive patients and this fact has
been as a barrier to blood pressure control in this
population.(1,4)
An important factor for determining interference in care for people with chronic diseases is related to the terms adherence and compliance. Although
interconnected and relating to the same action, they
differ because they indicate the act (compliance)
and the effect (adherence) of this action. Thus,
compliance with treatment of a disease means to
follow the treatment exactly as proposed by health
professionals. (4)
It is important to conduct studies on the subject of compliance that identify the influences of
human behavior and the socioeconomic structure
for non-compliance with a treatment regimen for
hypertension considered relatively simple and sustained on the triad of medication, balanced diet and
physical activity.
Thus, specific interventions can be made in the
monitoring of this population, such as enforcing
public health programs and establishing quality indicators, and then evaluate those programs.
The aim of this study was to assess the compliance with clinical treatment of hypertension in the
population assisted by a unit of the Family Health
Strategy (ESF - Estratégia de Saúde da Família).
Methods
This is a cross-sectional study carried out in a unit
of the Family Health Strategy in the city of Montes
Claros, Minas Gerais, southeastern Brazil. Initially, was used the Clinical Management System of
Hypertension and Diabetes Mellitus of the Primary
Care (SIS-HIPERDIA - Sistema de Gestão Clínica de Hipertensão Arterial e Diabetes Mellitus da
Atenção Básica).
In total, participated of the study 140 people in outpatient treatment for arterial hypertension and residents of the covered area. It was a
non-probabilistic sample, and those with comorbidities were excluded.
The used instruments were related to socio-clinical and epidemiological variables, linked to the
Morisky-Green test validated in Brazil, which assesses the attitudes of patients about the drug treatment of hypertension.(5)
Variables related to the object of the study were
presented using descriptive statistics. The Pearson’s
Chi-squared test or the Fisher’s exact test were used
for the comparison between compliance with treatment and the other variables.
In multivariate analysis, the dependent variable
of the research was non-compliance with treatment.
The associations between the dependent variable
and the study variables - socioeconomic, demographic, of lifestyle and knowledge of the disease
- were established by the Pearson’s chi-squared test
or the Fisher’s exact test.
In order to verify the factors associated with
non-compliance with treatment, was used the
multivariate logistic regression. Measures of risk
and odds ratio (OR) were estimated for each
variable individually in the model (crude OR),
and also the adjusted OR by the multiple regression model. In all statistical tests was considered
a significance level of 0.05. The statistical proActa Paul Enferm. 2014; 27(3):266-72.
267
gram used was the Statistical Package for Social
Science (SPSS), version 14.0.
The development of study followed the national
Results
Among the 140 investigated subjects, the majority are female (70.7%), aged between 40-49
years (42.1%), unmarried (50%). Regarding color/race, the highest proportion was declared as
non-white (70.7%).
With regard to education, 94 people (67.1%)
reported having completed the primary education, 17.1% were illiterate, and 15.8% had attended high school or college. With regard to
occupation, the majority, or 98 subjects (70%)
were classified as not economically active, being
away from work or retired. A total of 119 (85%)
subjects had a family income of only a minimum
wage, 108 (77.1%) subjects resided in homes
with fewer than five residents. In relation to the
condition of property 108 (77.1%) reported living in their own house.
Analyzing both groups of compliance and
non-compliance with antihypertensive treatment
and the demographic variables, similarities are observed between the two regarding gender, age, marital status, and race/color (Table 1).
Table 1. Demographic characteristic and compliance with
treatment
Compliance
Variables
Yes
n(%)
No
n(%)
p-value
0.222
Gender
Male
15(36.6)
26(26.3)
Female
26(63.4)
73(73.7)
Age (years)
< 50
34(82.9)
75(75.8)
≥ 50
07(17.1)
24(24.2)
0.353
Marital status
Married
05(12.2)
10(10.1)
Unmarried
36(87.8)
89(89.9)
0.767
Color/Race
White
10(24.4)
21(21.2)
Non-white
31(75.6)
78(78.8)
41(100.0)
99(100.0)
Total
268
Acta Paul Enferm. 2014; 27(3):266-72.
0.680
The groups are also similar with respect to
education, occupation, number of people in the
house and condition of employment. However, a significant association was found between
the income and compliance with treatment (p =
0.039), demonstrating heterogeneity in relation
to this variable (Table 2).
Table 2. Socioeconomic characteristic and compliance with
treatment
Compliance
Variables
Yes
n(%)
No
n(%)
p-value
Iliterate
5(12.2)
19(19.2)
0.553
Primary school
30(73.2
64(64.6)
Secondary school or higher
06(14.6)
16(16.2)
Yes
14(34.1)
28(28.3)
No
27(65.9)
71(71.7)
Education
Profissional activity
0.491
Family income
< 1 minimum wage
09(22.0)
09(9.1)
≥ 1 minimum wage
32(78.0)
90(90.9)
< 5 people
32(78.0)
21(21.2)
≥ 5 people
09(22.0)
78(78.8)
Owner
30(73.2)
76(76.8)
Not owner
11(26.8)
23(23.2)
41(100.0)
99(100.0)
0.039
Number of people
0.870
Condition of housing
Total
0.471
The hypertensive groups of compliance and
non-compliance with treatment were similar with
respect to the guidance, the Body Mass Index BMI and changes in habits after the guidance.
In relation to body mass index - BMI, 114
(81.4%) people are classified between overweight
and obesity (84%), reporting to have received guidance on diet (88.6%), physical activity (84.3%),
cigarette smoking (62.9%) and alcohol (60.0%),
and also on the use of medicines (96.4%). In relation to the guidance received, the majority, or 94
(67.1%) subjects reported the Community Health
Agent as responsible for it.
Regarding knowledge of the disease, it was observed that the groups were homogeneous for the
following variables: time of diagnosis, treatment
time, attendance to medical appointments and receipt of home visits (Table 3).
As for the distribution of non-compliance
with treatment by hypertensive subjects associated
with exclusive guidance given by the Communi-
Table 3. Knowledge about the disease
Compliance
Variables
Yes
n(%)
No
n(%)
p-value
<9
26(63.4)
62(62.6)
0.930
≥ 9
15(36.6)
37(37.4)
Time of diagnosis (years)
Treatment time (years)
<9
25(61.0)
61(61.6)
9 |– 10
16(39.0)
38(38.4)
0.944
Attendamce to appointments
Yes
39(95.1)
85(85.9)
No
2(4.9)
14(14.1)
Yes
39(95.1)
95(96.0)
No
2(4.9)
4(4.0)
0.150
Receive home visits
1.000
Compliance with treatment (self-reported)
Yes
41(100.0)
69(69.7)
No
0
30(30.3)
41(100.0)
99(100.0)
Total
-
ty Health Agent (ACS – Agente Comunitário de
Saúde), the hypertensive were 2.21 times more likely of ‘non-compliance’ with treatment compared to
those not advised by the Community Health Agent,
regardless of family income, use of drugs and cigarettes. (Crude OR 95% CI (1.08 - 4.91) adjusted
OR (95% CI) = 2.21 (1.08 - 4.85; p = 0.033), The
p-value of the adjustment model test (Hosmer &
Lemeshow) is 0.94 in the model adjusted to household income, use of drugs and cigarettes, and in the
model without adjustment variable.
Discussion
This research with descriptive analysis obtained
by a cross-sectional study has some limitations
related to selection bias, i.e., because the data
were collected in a single unit of health as well
as based on self-reported information, it does
not allows us to make generalizations regarding
compliance with treatment by hypertensive people registered in other services.
Compliance with treatment of chronic conditions is a major challenge for public health and
nursing. Thus, the results of this study may help
nurses with defining strategies, as carrying out new
researches and educational interventions that contribute to increase the effectiveness of actions taken
to control hypertension.
The largest portion of the study population is
female. The prevalence of hypertension in the female population has been suggested by some studies carried out in Brazil and abroad, reflecting the
increased demand of this population for health
services. In Brazil, this fact may be related to the
increased availability of women to participate in activities developed in health services, in particular in
the Family Health Strategy.(6-9)
Studies point to the fact that women seek treatment as a cultural reflection motivated by how the
health services are organized (opening hours, location), and the higher life expectancy of women
compared to men, which is attributed to cardiovascular protection and the lower consumption of tobacco and alcohol.(10-12)
The most common age in the study population
was the range between 40 and 49, different from
information found in the literature, which indicates
that hypertension is prevalent in the male population of around 50 years old, and equating the female population after menopause.(6,7,11,12) This was
observed in this study because it was based on record data rather than population survey, characterizing as a possible selection bias.
Regarding the level of education, in this
study predominated the complete elementary
education, an important social indicator and determinant factor in the health-disease process.
Despite not having found a significant association between education and compliance with
treatment, the literature shows a falling trend
in mean blood pressure and hypertension with
higher levels of education, considering that the
influence of other social factors and conditions
of occupation may occur.(13,14)
Individuals with lower education and chronic diseases have difficulties in understanding both
the prescription as the information obtained in the
drug leaflet regarding the correct dosage, indications, contraindications and warnings, since these
limitations of understanding increase the risk of errors with medication.(15,16)
Regarding marital status, individuals classified as
‘separated’ had a higher frequency of hypertension.
We can infer that the formal or informal support
Acta Paul Enferm. 2014; 27(3):266-72.
269
that people receive from their partners may improve
compliance with treatment. People with companions are two times more likely to comply with treatment compared to those without partners.(17)
As for the color/race, most participants consisted of non-whites. Studies that approach gender and
color in Brazil show a predominance of black women with hypertension by up to 130% compared to
white and that, in Brazil, the impact of miscegenation on the disease is not known with accuracy.(4,18)
The significant association (p = 0.039) found
between non-compliance with treatment and financial resources can be corroborated by studies
indicating that the low purchasing power not only
hinders survival but also the access to antihypertensive medications. In this sense, it is observed in
the literature that lower economic levels had higher
prevalence of hypertension and exposure to risk factors for increasing blood pressure.(4,6,7,10,19)
The compliance with treatment is considered
a complex behavioral process strongly influenced
by the environment, individuals, health care professionals and health care, covering the biological,
psychological, socioeconomic and cultural dimensions. It is observed that both the received health
guidance as the habits and living conditions like
excess weight, alcohol intake, smoking, poor diet,
and stress, among others, constitute risk factors for
non-maintenance of blood pressure control.(1,2,19,20)
By analyzing the distribution of hypertensive subjects according to the guidance received
on health and lifestyle habits, it was observed
that the majority (81.4%) mentioned having
obtained information on diet, physical activity,
smoking and alcohol intake. These subjects signaled changes in their lifestyle habits after receiving such information.
The effect of educational programs on compliance with drug treatment indicates low compliance with these recommendations by the
studied population. Education constitutes one
of the most successful interventions to improve
compliance and self-management of people with
chronic diseases, especially if the educational
program is centered on the beliefs and concerns
about their conditions of health and treatment.
270
Acta Paul Enferm. 2014; 27(3):266-72.
Hence the need for a greater number of investigations about the self-reported change in habits,
in order to assess the effectiveness and quality of
guidance given by health professionals.(21-25)
Regarding the distribution of hypertensive subjects according to treatment time, attendance to
medical appointments, receipt of home visits and
self-reported compliance, it is observed that those
who report themselves as non-compliant, in majority, have time of diagnosis and treatment time of less
than nine years. These are the people who attend
consultations more often and receive home visits.
These data are similar to the results shown by studies on the subject of compliance with treatment and
control of hypertension, as well as the fragility of
self-reported data by study subjects in research.(26,27)
There was a statistically significant relationship (p <0.05) between the non-compliance with
treatment when the health guidance was given
by the community health agent only. This may
be linked to the short time of activity that these
professionals have in this area without any training or qualification. These findings are consistent
with another study indicating that the process of
qualification of health agents has been fragmented and insufficient to develop the necessary skills
for preventive health actions and insertion in the
line of care of hypertension.(28,29)
The Morisky-Green test showed low compliance with drug therapy for the treatment of
hypertension (70.7%), a fact mainly related to
forgetting to take doses of medication. Similar
results were found in observational studies that
demonstrated the lack of compliance of hypertensive patients associated with forgetfulness in
the ingestion of medication.(18,22)
When asked about the reason for non-compliance, 30 (21.4%) subjects cited the lack of medicines in the unit as a cause. In Brazil, despite representing a large part of investment in public health,
the free dispensing of medicines is still not enough
to cover the current needs.
Thus, it is necessary to invest in improving the
quality of care offered to the population, improving
user embracement, increasing the resolutivity across
the entire network of services, encouraging account-
ability of health professionals and staff for the care
of patients, and integrating services through lines
of care and greater coordination among the various
levels of the local health system.(30)
The lack of training of community workers in
the survey and in meeting the needs of hypertensive patients indicates the importance of developing
strategies and professional training that enable the
knowledge and application of lines of care for hypertension, in order to improve the quality of primary care provided.
Conclusion
The income and the guidelines provided by community health workers were significant factors for
adherence to the recommended treatment.
Collaborations
Martins AG; Chavaglia SRR; Ohl RIB; Martins
IML and Gamba MA declare to have contributed
to the conception and 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.
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Original Article
Nasal colonization by Staphylococcus
sp. in inpatients
Colonização nasal por Staphylococcus sp. em pacientes internados
Gilmara Celli Maia de Almeida1
Nara Grazieli Martins Lima1
Marquiony Marques dos Santos1
Maria Celeste Nunes de Melo2
Kenio Costa de Lima2
Keywords
Nursing service, hospital; Clinical
nursing research; Nursing care; Nasal
mucosa/microbiology; Staphylococcus;
Nasopharynx/microbiology; Inpatients
Descritores
Serviço hospitalar de enfermagem,
Pesquisa em enfermagem clínica;
Cuidados de enfermagem; Mucosa
nasal/microbiologia; Staphylococcus;
Nasofaringe/microbiologia; Pacientes
internados
Submitted
April 2, 2014
Accepted
May 26, 2014
Gilmara Celli Maia de Almeida
Rua André Sales, 667, Campus Caicó,
Caicó, RN, Brazil. Zip Code: 59300-000
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400046
Abstract
Objective: To analyze nasal colonization by Staphylococcus sp. its resistance to methicillin, and associated
factors in inpatients.
Methods: Nasal sample collection, antimicrobial susceptibility tests, and analysis of medical records of
inpatients (n=71) were performed, and a questionnaire was applied. Data were analyzed by descriptive and
inferential statistics using the chi-square, Student’s t, and Mann-Whitney tests (α=5%).
Results: Nearly half (44.4%) of the patients who were significantly associated with prolonged antibiotic
treatment (p=0.02) was infected with methicillin-resistant Staphylococcus sp.. A significant association was
observed between patients with sensitive strains and absence of antibiotic treatment prior to sample collection
(p=0.02) or absence of wounds (p=0.003).
Conclusion: Strains of methicillin-resistant Staphylococcus sp. were found, and there was no significant
difference between the S. aureus species and the coagulase-negative Staphylococci groups, which indicates
the degree of spread of methicillin resistance among different species of Staphylococcus.
Resumo
Objetivo: Analisar a colonização nasal por Staphylococcus sp., sua resistência à meticilina e fatores associados
em pacientes internados.
Métodos: Foram realizados coleta de amostra nasal, testes de susceptibilidade antimicrobiana e análise
de prontuários médicos de pacientes internados (n=71), e foi aplicado um questionário. Os dados foram
analisados por meio de estatística descritiva e inferencial usando os testes c2, t de Student e Mann-Whitney
(α=5%).
Resultados: Cerca de metade (44,4%) dos pacientes, significativamente associados ao tratamento antibiótico
prolongado (p=0,02) estavam infectados por Staphylococcus sp resistentes à meticilina. Observou-se uma
associação significativa entre pacientes com cepas sensíveis e ausência de tratamento com antibiótico antes
da coleta (p=0,02) ou ausência de feridas (p=0,003).
Conclusão: Foram encontradas cepas de Staphylococcus sp. resistentes à meticilina e não houve diferença
significativa entre a espécie S. aureus e os grupos de estafilococos coagulase negativos, o que indica o grau
de disseminação da resistência à meticilina entre diferentes espécies de Staphylococcus.
Universidade do Estado do Rio Grande do Norte, Caicó, RN, Brazil.
Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil.
1
2
Acta Paul Enferm. 2014; 27(3):273-9.
273
Introduction
Excessive use of antimicrobial agents or inappropriate empirical treatment have contributed to the
growing number of infections by multi-resistant microorganisms in both the community and hospital
environment.(1) As a result, the treatment of patients
with these infections is becoming more complex,
greatly increasing the costs of both hospitalization
and treatment of these patients in public hospitals.
(2)
Staphylococcus sp., mainly S. aureus, is commonly
found in the skin and mucosa of humans (especially
in the anterior region of the nasal passages), being
among the microorganisms most resistant to antibiotics.(3) It is one of the main pathogens that colonizes healthy individuals in the community, leading to
infection in patients admitted in hospitals.(4,5)
In this context, it is worth emphasizing the
worldwide increase in the prevalence of methicillin-resistant S. aureus (MRSA).(6) This agent causes
serious infections, whether in hospitalized individuals or otherwise, emphasizing the importance of epidemiological vigilance in detecting development of
resistance in both the community and in health care
services.(6) In addition, coagulase-negative Staphylococci (CoNS) act as a reservoir of resistance genes,
although these microorganism are less virulent. The
presence of methicillin-resistant coagulase-negative
Staphylococci (MRCoNS) in hospital environments
can lead to the emergence of MRSA.(7,8)
Presence of MRSA or MRCoNS in asymptomatic patients is a major source of contamination.
Their early identification can reduce the risk of
colonization of patients and cross-transmission between patients and health professionals, especially
in hospital environment.(7,9) Although this theme is
important, it has been little studied in the northeast
of Brazil, especially in interior municipalities, which
are characterized by marked social and economic
inequality and where a large part of the population
live in conditions of social deprivation. Therefore,
studies in this region are necessary to support implementation and monitoring of measures of control to both minimize the potential spread of this
microorganism and subsequently reduce the risk of
hospital infections.(10)
274
Acta Paul Enferm. 2014; 27(3):273-9.
Thus, the aim of this study was to describe nasal
colonization by Staphylococcus sp., especially S. aureus, their respective sensitivity to methicillin, and
associated factors in patients in a referral hospital in
the interior of northeast Brazil.
Methods
A cross-sectional study was performed in the Hospital Regional do Seridó, in Caicó, Rio Grande do
Norte (RN), a municipality in northeast Brazil.
This hospital is a referral institution in the interior
of RN, where patients from more than 14 municipalities are treated. Due to many reasons, there is a
lack of research studies in hospital in the interior of
northeast Brazil. Furthermore, this region has some
of the lowest social and economic indicator scores
in the country,(11) making investigation more difficult, especially if it requires laboratory and infrastructure support.
Patients admitted to the medical and surgical clinics, and Intensive Care Unit (ICU) of the
Hospital Regional do Seridó participated in the
study. The subjects were enrolled in parallel with
another study, in which the investigators aimed to
identify Staphylococcus aureus in wounds of patients.
This study included individuals with skin sores or
wounds on the day of collection, or those without
wounds who were hospitalized within 12 hours prior to collection. Individuals without wounds were
accompanied during hospitalization to verify if
pressure ulcers or post-surgical infections developed
while they were in the hospital.
Nasal collection was performed in patients
included in the study described above in order to
verify if there was colonization by Staphylococcus
sp. Only the first 30 patients were considered for
calculation of sample size. In the first analysis,
74% of Staphylococcus sp. isolated in the nostrils
of patients hospitalized were found. We assumed
a margin of error of 15%, a design effect of 1%,
and a non-response rate of 20% to estimate the
sample size (71 patients).
Therefore, subjects were included until the sample size was complete (n=71) to characterize nasal
Almeida GC, Lima NG, Santos MM, Melo MC, Lima KC
colonization by Staphylococcus sp.. Data were collected during the first semester of 2012.
Medical records were consulted in order to
describe the factors related to the hospitalization/antibiotic treatment of the studied population. In addition, the patients completed a
questionnaire containing questions related to
age, gender, municipality of origin, presence of
comorbidities or systemic impairment, and use
of antibiotics prior to hospitalization, among
other factors that could influence the frequency
of methicillin-resistant Staphylococcus sp..
Samples from the nasal mucosa of patients
were collected using a sterile swab soaked in
0.85% saline. For each patient, the swab was
inserted into both nasal cavities and the sample
was then placed in sterile tubes containing Brain
Heart Infusion (BHI) broth (with 7.5% NaCl),
which were then packed in styrofoam boxes with
crushed ice and transported to the microbiology
laboratory of the university. The samples were
incubated in the laboratory (37 °C; 24 h). After this period, the samples were inoculated in
mannitol salt agar medium and grown in a bacteriological incubator (37 °C; 48 h). The staphylococcal colonies were then subjected to Gram
stain, catalase, and free coagulase tests. Samples
positive for Gram, catalase, and coagulase were
classified as Staphylococcus aureus; samples negative for coagulase test were classified as coagulase-negative Staphylococcus (CoNS). All samples
identified as Staphylococcus sp. were submitted
to antibiogram analysis using the disk diffusion
method to verify their resistance to methicillin.
The Chi-square or Fisher’s exact test were utilized to verify the association between dependent
(resistance or sensitivity to methicillin and presence
of S. aureus or CoNS) and qualitative independent
variables. The Prevalence Ratio (PR) was utilized
to analyze the degree of association. The Student’s
t-test was utilized to ascertain whether there was a
significant difference between the groups of dependent variables in relation to the patients’ age. The
other quantitative independent variables (number
of days of antibiotic use prior to sample collection,
number of days of hospitalization, and number of
hospitalizations in the last year) were analyzed using
the Mann-Whitney test. A significance level of 5%
was used with the Stata 10.0 statistical software.
The development of the study met the national
Results
A total of 38 (53.5%) patients were female and
33 (46.5%) were male. Patients had a mean age
of 63±21 (standard deviation, sd) and time of formal education of 3.8±3.7 years (sd). A total of 40
(56.3%) patients were in the medical clinic, 20
(28.2%) patients were in the surgical clinic, and
11 (15.5%) in the ICU. Wounds (n=23; 32.4%),
fractures or surgery (n=8; 11.3%), and renal or
post-surgical infections (n=8; 11.3%) were the most
frequent reasons for hospitalization.
As shown in table 1, 63 (88.8%) patients had
Staphylococcus sp. (either S. aureus or CoNS) in
their nostrils. Among the 11 patients who died,
four (36.4%) had S. aureus and five (45.4%) had
CoNS in their nostrils; in the samples from two
(18.2%) of them, no bacteria grew or was identified
as staphylococci. Among the resistant strains, the
antibiogram for Staphylococcus sp. showed that seven (25%) were S. aureus and 21 (75%) were CoNS.
However, this difference was not statistically significant (p=0.45). The general descriptive results for
resistance/sensitivity of Staphylococcus sp. to methicillin, without specifying species or group, is shown
in table 1.
Table 1. Absolute and percent distribution, identification, and
behavior of nasal Staphylococcus sp. relative to methicillin
Dependent variables
n(%)
Presence of nasal Staphylococcus sp
S. aureus
20(28.8)
Coagulase-negative Staphylococcus
43(60.6)
No growth of Staphylococcus or bacteria
8(11.3)
Behavior of Staphylococcus sp. relative to methicillin
Resistant
28(44.4)
Susceptible
35(55.6)
Behavior of S. aureus relative to methicillin
Resistant
Susceptible
7(9.9)
64(90.1)
Acta Paul Enferm. 2014; 27(3):273-9.
275
Of the 7 samples of nasal MRSA, 71.4%
were found in patients from the medical clinic
and 28.6% in patients from the surgical clinic or ICU. The patients with MRSA had some
kind of systemic impairment (71.4%), diabetes
(28.6%), suffered from cancer (28.6%), and had
been hospitalized in the previous year (57.1%).
Most patients (57.1%) were from a municipality
with more than 60,000 inhabitants and 28.6%
had died.
Data in table 2 allow identifying an association
between dependent and independent variables. A
statistically significant association was found only
with antibiotic resistance, prior use of antibiotics,
and presence of wounds.
The difference between groups of dependent variables and quantitative variables can be seen in table
3. A statistically significant difference was found only
between antibiotic resistance and number of days of
use of antibiotics prior to sample collection.
Table 2. Patient characteristics associated with presence of Staphylococci (CoNS and S. aureus) into the nostril and their susceptibility
to methicillin
Susceptibility to methicillin
Characteristics
Resistant
No resistant
n(%)
n(%)
Staphylococcus sp
S. aureus
CoNS
n(%)
n(%)
PR
95%CI
p-value
11(37.9)
18(62.1)
1.02
0.58-1.77
0.95
9(26.5)
25(73.5)
10(28.6)
25(71.4)
2.00
1.04-3.84
0.02
10(35.7)
18(64.3)
9(27.3)
24(72.7)
11(36.7)
19(63.3)
13(29.5)
31(70.5)
7(36.8)
12(63.2)
13(35.1)
24(64.9)
7(26.9)
19(73.1)
14(27.5)
37(72.5)
6(50.0)
6(50.0)
PR
95%CI
1.43
0.69-2.97
0.80
0.39-1.65
0.74
0.36-1.54
0.80
0.38-1.69
1.30
0.60-2.82
0.55
0.27-1.13
p-value
Gender
Male
13(44.8)
16(55.2)
Female
15(44.1)
19(55.9)
0.33
Use of antibiotics prior to sample collection
Yes
20(57.1)
15(42.9)
No
8(28.6)
20(71.4)
Yes
15(45.5)
18(54.5)
No
13(43.3)
17(56.7)
Yes
25(56.8)
19(43.2)
No
3(15.8)
16(84.2)
Caicó
14(37.8)
23(62.2)
Other city
14(53.8)
12(46.2)
Yes
25(49.0)
26(51.0)
No
3(25.0)
9(75.0)
0.54
Hospitalization in the last year
1.05
0.60-1.83
0.87
0.42
Presence of wound
3.60
1.23-10.49
0.003
0.57
City
0.70
0.41-1.21
0.21
1.96
0. 71-5.43
0.13
0.49
Systemic impairment
0.17
Clinic
ICU
4(40.0)
6(60.0)
1
Medical
19(51.4)
18(48.6)
0.78
0.34-1.77
Surgical
5(31.3)
11(68.8)
1.28
0.45-3.66
Yes
17(51.5)
16(48.5)
No
11(36.7)
19(63.3)
Yes
8(33.3)
16(66.7)
No
20(51.3)
19(48.7)
Yes
4(66.7)
2(33.3)
No
24(42.1)
33(57.9)
0.38
3(13.0)
7(70.0)
1
13(35.1)
24(64.9)
0.85
0.30-2.42
4(25.0)
12(75.0)
1.20
0.34-4.28
9(27.3)
24(72.7)
11(36.7)
19(63.3)
0.74
0.36-1.54
6(25.0)
18(75.0)
14(35.9)
25(64.1)
0.70
0.31-1.56
3(50.0)
3(50.0)
17(29.8)
40(70.2)
1.68
0.69-4.10
0.76
Diabetes
1.40
0.79-2.50
0.24
0.42
Cardiovascular disorders
0.65
0.34-1.24
0.16
0.37
Cancer
1.583
0.83-3.01
CoNS – Coagulase-negative Staphylococcus; ICU – Intensive Care Unit; PR – Prevalence Ratio; 95%CI – 95% Confidence Interval
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Acta Paul Enferm. 2014; 27(3):273-9.
0.39
0.37
Table 3. Descriptive and inferential statistics between dependent and independent quantitative variables
Quantitative independent variables
Dependent variables
Nº days with antibiotic
prior to collection
Age
Mean
(standard deviation)
p-value
Median
(quartile 25-quartile 75)
p-value
Nº days hospitalized
in a hospital
Median
(quartile 25-quartile 75)
Nº hospitalizations
in the last year
p-value
Median
(quartile 25-quartile
75)
p-value
Staphylococcus sp. resistance to methicillin
MRSA
65.7(19.5)
MSSA
61.8(23.0)
0.48
3.5(0.2-9.7)
0.02
0(0.0-3.5)
5.4(3.0-11.2)
3(2.0-5.4)
0.05
1(0.0-1.7)
1(0.0-1.0)
0.89
Staphylococcus sp
S. aureus
59.5(24.1)
CoNS
65.4(20.1)
0.31
0.5(0.0-3.0)
0.15
2.0(0.0-9.0)
3(2.2-5.4)
5.4(2.0-10.0)
0.20
1(0.0-1.0)
1(0.0-2.0)
0.57
CoNS – Coagulase-negative Staphylococcus; MRSA – methicillin-resistant S. aureus; MSSA – methicillin-sensitive S. aureus a
Discussion
Although Staphylococcus sp. is part of the resident
microbiota, being mainly found in the nasal cavities,(12) they are also frequently found in hospital
environment as the main agent of various infections.(13) In the present study, almost 90% of patients had Staphylococcus sp. in their nostrils, and
most were CoNS rather than S. aureus. Although
MRSA is more frequently studied, the mecA gene,
responsible for its resistance to methicillin, can also
be found in strains of methicillin-resistant coagulase-negative Staphylococcus (MR-CoNS).(7,8,14,15)
The results of present study are in agreement with
others(4,11,16) in which S. aureus was not the most
prevalent. The nasal vestibules of about 20% of
the healthy population were colonized by S. aureus,(4,5) an important pathogen that can spread
throughout the community and has a high resistance potential.(14,17) However, the pathogen-host
interactions are partially understood, and this is
our reason for investigating this subject.(5)
Advanced age, prior hospitalization, use of intravascular catheter, prior MRSA colonization,
presence of wounds and/or ulcers, prolonged use of
antibiotics, and severity of disease were considered
risk factors for hospital MRSA. It should be stated
that the bacteria must colonize a patient who has
not been recently hospitalized, used antimicrobial
agents, or had a catheter implanted to be considered a community MRSA.(18,19) In this sense, most
patients involved in our study were admitted to the
hospital for treatment of an injury, bedsore, diabetic
foot, or erysipela. Additionally, most of them were
subject to risk factors related to hospital admission,
which favored colonization by hospital MRSA. Furthermore, there was a history of prior hospitalization in more than half of the cases in the study with
MRSA and most patients had systemic impairment.
Many studies have reported the presence of
MRSA strains in the nasal mucosa, even at low
levels,(2,4-6,10,20)associated with greater morbidity
and mortality. In the present study, the prevalence
of MRSA was almost 10%, a value similar to that
obtained in other studies involving hospitalized
patients or health professionals.(15,21) There are reports of nasal colonization of healthy individuals by
MRSA (1-8%), which represent a potential risk factor for subsequent infection by S. aureus.(15,19)
Although much attention has been directed to
the resistance of S. aureus, CoNS should also be
studied due to an increase in the resistant strains. In
the present study, the level of resistance to methicillin was relatively high, with similar values for both
S. aureus and CoNS. Among nursing students,(3) all
samples of S. aureus isolated in their nostrils were
sensitive to oxacillin, whereas 79 samples of CoNS
were resistant to it; 10 of these samples were resistant to both oxacillin and cefoxitin. Similarly,
almost 50% of the CoNS were resistant to methicillin among pharmacy students.(7) To verify this
relationship among health workers, a study with
health professionals found that more than 50% of
S. epidermidis isolated from their nasal mucosae
were resistant and positive for the mecA gene.(8) In
this context, we found that resistance for both S.
aureus and CoNS among hospitalized patients is
equivalent, bringing a greater concern with cross
contamination in the hospital environment by resistant strains of Staphylococcus.
Acta Paul Enferm. 2014; 27(3):273-9.
277
Presence of methicillin-sensitive Staphylococcus sp. was significantly associated with non-use by
patients of antibiotic prior to sample collection, as
well as absence of wounds on their bodies. On the
other hand, methicillin-resistant Staphylococcus sp.
exhibited a significant statistical difference between
the number of days under antibiotic therapy prior
to data collection and the resistant strains subject
for more days to antimicrobial therapy. In a study
with hospital patients in Madagascar, presence of
S. aureus in their nostrils was significantly associated with prior use of antimicrobial agents and prior
hospitalization, whereas prior use of antibiotics was
significantly associated with presence of MRSA.(19)
Another factor described in the literature,
which is significantly associated with the presence
of MRSA, is prior hospitalization of the patient.(19)
In the present study this was however not evident,
since hospitalization in the previous year was not
significant for the presence of either resistant Staphylococcus sp. or S. aureus. Nevertheless, more than
half of the patients with MRSA in the study were
admitted to the hospital in the previous year.
There was no significant association between
Staphylococcus sp. (S. aureus or CoNS) in the nostrils
and any of the independent variables of the study,
whether sociodemographic or relative to the medical
profile of the patient. Regarding the CoNS, a study
in French Guiana(12) also did not find any association between the transport of methicillin-resistant
CoNS and sociodemographic characteristics and
those relative to health. Thus, the high frequency of
colonization by methicillin-resistant CoNS probably depends on the overall prevalence of transport
of these strains in the community and not on individual characteristics. (12) This fact is relevant since
it indicates the importance of the upper air waves
in the acquisition and transmission of microorganisms, as literature indicates that nasal colonization
is responsible for the colonization of the cutaneous
surface of the body.(6) Control measures for routine
application require continued education, periodic
bacteriological surveillance of those who work in
the hospital environment, and application of best
practices in infection control while they take care
of patients.
278
Acta Paul Enferm. 2014; 27(3):273-9.
Conclusion
Strains of methicillin-resistant Staphylococcus sp.
were found among patients in the hospital where the
study was conducted. However, no significant difference was found between the S. aureus species and
the CoNS group, showing the scale of the spread
of methicillin resistance among different species of
Staphylococcus. In this perspective, association of
bacterial resistance with prior use of antibiotics for a
long period, indicates that their indiscriminate use
is dangerous.
Collaborations
Almeida GCM; Lima NGM; Santos MM; Melo
MCN and Lima KC contributed to the project design, analysis, and interpretation of data,
drafting the article, critical revision, and final
approval of the manuscript.
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FL, et al. [Colonization by Staphylococcus aureus among the nursing
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16.Scribel LV, Scribel MV, Bassani E, Barth AL, Zavascki AP. Lack of
methicillin-resistant Staphylococcus aureus nasal carriage among
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2012. 293p. Portuguese.
17. Pardo L, Vola M, Macedo-Vinas M, Machado V, Cuello D, Mollerach M, et
al. Community-associated methicillin-resistant Staphylococcus aureus
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Acta Paul Enferm. 2014; 27(3):273-9.
279
Original Article
Occurrence of occupational accidents
involving potentially contaminated
biological material among nurses
Ocorrência de acidentes de trabalho com material biológico
potencialmente contaminado em enfermeiros
Marília Duarte Valim1
Maria Helena Palucci Marziale1
Miyeko Hayashida1
Miguel Richart-Martínez2
Keywords
Accidents, occupational; Universal
precautions; Security measures;
Occupational health nursing; Exposure
to biological agents
Descritores
Acidentes de trabalho; Precauções
universais; Medidas de segurança;
Enfermagem do trabalho; Exposição a
agentes biológicos
Submitted
April 7, 2014
Accepted
May 26, 2014
Marília Duarte Valim
Bandeirantes Avenue, 3900, Ribeirão
Preto, SP, Brazil. Zip Code: 14040-902
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400047
280
Acta Paul Enferm. 2014; 27(3):280-6.
Abstract
Objective: To investigate the occurrence and characteristics of accidents involving potentially contaminated
biological material in nurses.
Methods: Cross-sectional study involving 121 nurses. The research instrument was a self-applied
questionnaire with sociodemographic and occupational accident-related variables.
Results: Sixty-five (53.8) nurses were victims of occupational accidents involving exposure to potentially
contaminated biological material. Sixty-three (52.1%) were related to piercing-cutting materials and 22
(18.2%) to exposure of the mucosa and/or non-intact skin. No statistically significant difference between
the groups was found in terms of accident events and reporting (p=0.791 and p=0.427); knowledge of
the immune response (p=0.379); change of piercing-cutting material collector (p=0.372) and training on
standard precautions (p=0.158). A statistically significant different in the training was found (p=0.014), as
nurses working at smaller establishments indicated greater desire to participate.
Conclusion: Accidents are frequent among the nurses and training is positively related with adherence to
standard precautions.
Resumo
Objetivo: Investigar ocorrência e características dos acidentes com material biológico potencialmente
contaminado em enfermeiros.
Métodos: Estudo transversal que incluiu 121 enfermeiros. O instrumento de pesquisa foi um questionário
autoaplicável com variáveis sociodemográficas e relacionadas a acidentes de trabalho.
Resultados: Em relação à ocorrência de acidente do trabalho com exposição a material biológico potencialmente
contaminado entre enfermeiros, 65 (53,8%) foram vítimas. Destes, 63 (52,1%) por perfurocortantes e 22
(18,2%) por exposição à mucosa e/ou pele não íntegra. Não houve diferença estatisticamente significativa
entre os grupos quanto à ocorrência e notificação do acidente (p=0,791 e p=0,427); conhecimento da resposta
vacinal (p=0,379); troca de recipiente de perfurocortantes (p=0,372) e treinamento sobre precauções padrão
(p=0,158). Com relação ao treinamento foi verificada diferença estatisticamente significativa (p=0,014) uma
vez que enfermeiros nos estabelecimentos menores relataram maior desejo de participação.
Conclusão: Os acidentes são frequentes entre os enfermeiros e o treinamento relaciona-se positivamente à
adesão às precauções-padrão.
Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
Universidad de Alicante, Alicante, Spain.
1
2
Valim MD, Marziale MH, Hayashida M, Richart-Martínez M
Introduction
The double goal of the standard precautions is to
protect health professionals against possible occupational contamination in care delivery and to prevent healthcare-related infections.(1) In occupational
health, the possibility of contamination by occupationally relevant pathogens like the HIV virus and
the HBV and HCV virus can be prevented.(2) In
1996, 18 years ago, the Centers for Disease Control and Prevention (CDC) established the standard precautions, which contain the main concepts
of universal precautions and isolation of body substances, based on the principle that any body fluids
(except sweat) can contain infectious agents.(3)
The infection by the HIV virus in the United
States among professionals who did not report other than occupational risk factors was investigated in
a CDC protocol entitled “Cases of Public Health
Importance” (COPHI).(4)
In that source, it is reported that records between
1981 and 2010 indicate that 57 North American
workers were victims of seroconversion after occupational accidents involving exposure to potentially
contaminated biological material, although at least
143 cases are under investigation, the most recent
of which happened in 2009. Therefore, the number
of professionals who caught the infection is uncertain. In addition, there is possible underreporting.
In developing countries, the surveillance and
control systems need to be improved and health establishments need to encourage reporting,(5,6) as there
are no precise data about the number of cases of seroconversion to HIV and hepatitis B and C among
health professionals in the Brazilian context.
In Brazil, occupational accidents involving exposure to potentially contaminated biological material are considered a health problem of compulsory reporting and should be notified on a form
standardized by the Ministry of Health in the National Disease Notification System - SINAN-NET
and in sentinel networks, such as the Occupational
Health Referral Centers - CEREST.(7) In a study
undertaken to analyze these accidents, important
gaps were appointed, showing the need to train the
professionals responsible for the records.(6) Studies
indicate the need for training and awareness-raising of the workers about the adherence to standard
precautions(8,9), as these accidents are still frequent
and can entail severe consequences for the workers’
physical and psychosocial wellbeing.(10)
Adherence to standard precautions is the main
strategy to protect workers against exposure to
transmissible pathogens and to protect patients,(11)
but adherence is below recommended levels.(8,12) A
study found that training and knowledge about the
theme positively influence the adherence.(13) In the
same context, a study at hospitals and medical centers in Ethiopia identified that more than half of the
health workers possessed inappropriate knowledge
about the standard precautions and that 95.5% actually wanted to receive some kind of training.(14)
Adherence to infection control and safety
practices can also be influenced by the size of the
establishments. Studies show that adherence to
safety measures is higher in larger hospitals when
compared to smaller hospitals and establishments.
(5,15)
One of the reasons can be the fact that smaller establishments are generally more basic and have
a more limited structure and less activities of the
infection control commissions.(5)
It was observed that the constant presence of training, a prepared and exclusive team for infection control and patient safety, greater financial investments
and participation of organizational management in
these activities are positively related with better infection control practices.16,17)As the human and financial
resources vary significantly among different types of
health establishments, teaching hospitals tend to exert infection control practices more effectively than
municipal or philanthropic hospitals, which are often
smaller and receive less financial incentives.(17)
The objective in this study was to investigate
and compare the occurrence and characteristics of
accidents involving biological material in nurses at a
teaching hospital and smaller health establishments.
Methods
A cross-sectional study was undertaken at health
establishments in two Brazilian cities between SepActa Paul Enferm. 2014; 27(3):280-6.
281
Occurrence of occupational accidents involving potentially contaminated biological material among nurses
tember and December 2012, including one teaching hospital and three smaller institutions.
The teaching hospital is characterized as size IV
and is considered a referral center for high-quality
research areas. The items assessed for the characterization as size IV are: 300 beds or more, 30 of which
for the intensive care unit (ICU); more than eight
surgery rooms; reference level III for urgency and
emergency and ICU and four or more high-complexity sectors.(18) The smaller establishments include one philanthropic hospital, one private hospital that also offers beds to the Unified Health
System (SUS) and an emergency care unit affiliated
with a regional health insurance. The philanthropic institution offers 155 beds; the other hospital
78 beds, the emergency care service consists of an
emergency unit and a medication room and eight
beds for observation.
Nurses were included with at least three months
of professional experiences, who were not on holiday, medical leave or leave of absence. Professionals
in exclusively administrative functions or not present at the place of work after two consecutive attempts were excluded.
The sample was randomly composed of 120
nurses from the teaching hospital and the nurses
working at the smaller establishments who complied with the inclusion criteria, totaling 39 professionals. It should be highlighted that, in 2011,
411 nurses worked at the teaching hospital. The
final sample consisted of 121 nurses, 91 from the
teaching hospital and 30 from the smaller establishments. Therefore, the response rate corresponded to
75.8% for the university hospital and 77.0% for the
other establishments.
The questionnaire with sociodemographic characteristics included the following variables: sex;
work sector; birth date; education level; workplace
and length of professional experience. The following variables were considered related to the occurrence of an occupational accident with exposure to
potentially contaminated biological material: vaccination for Hepatitis B and knowledge about the
anti-HBs antibody; accident reporting; practice of
change of disposal container for piercing-cutting
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Acta Paul Enferm. 2014; 27(3):280-6.
material; participation and desire to participate in
training about standard precautions.
The responsible researchers provided the workers with the questionnaires during their work hours.
As the questionnaire was self-explained, the participants were advised to complete it when they had
time and to leave the completed questionnaires in a
sealed box in the nursing head’s office in each sector
for the researcher to collect. The box was available
for approximately two weeks in each sector and,
during the shift after they had received the questionnaire, the researcher contacted the nurses to know if
they had handed it in. In case they had not answered
it yet, the researcher used the occasion to remind
them about the importance of their participation.
The numerical variables are described using descriptive statistics, calculating the means, medians
and standard deviations. The nominal categorical
variables are described or displayed in frequency
tables. Pearson’s chi-square test was applied for the
categorical or dichotomous variables, such as “participation in training about SP”, “change of piercing-cutting material container” and “knowledge
about anti-HBs antibody” to compare whether
there was a statistically significant difference between the two groups of nurses. For the variables
“accident reporting” and “desire to participate in
training”, Fisher’s exact test was applied. For the
variable “number of accidents involving piercing-cutting material”, the Mann-Whitney test was
applied as no normal distribution was verified.
Brazilian and international standards for research
involving human beings.
Results
The participants mainly included women, between 20 and 40 years of age. The mean age at the
teaching hospital was 37.4 years (SD±8.95), median 35, maximum 58 and minimum 23 years.
At the smaller establishments, the mean age was
32.5 years, median 33, minimum 23 and maximum 50 years of age. The majority (51.2%) held
a specialist degree and only 8.3% a Master’s and/
or Doctoral degree, as demonstrated in table 1.
Table 1. Distribution of the nurses (n=121) according to sex, age
range, education and place of work
Variables
n(%)
Gender
Female
Male
110(90.9)
11(9.1)
Age range (years)
20 to 30
38(31.4)
31 to 40
50(41.3)
41 to 50
18(14.9)
≥ 51
12(9.9)
Missing data
3(2.5)
Education level
Higher
Specialization ongoing
Specialization
34(28)
6(5)
62(51.2)
Master’s ongoing
2(1.7)
Master’s
8(6.6)
Doctoral ongoing
Doctoral
6(5)
2(1.7)
Place of work
Teaching hospital
Emergency unit
32(26.4)
Teaching hospital
59(48.8)
Smaller health establishments
Philanthropic hospital
16(13.2)
Private hospital
7(5.8)
Emergency care
7(5.8)
The length of professional experience corresponded to between three months and five years
for 31.4%, between six and ten years for 23.1%,
between 11 and 15 years for 20.7% and 16 years or
more for 24.8%. The mean length of professional
experience was 10.1 years (SD 7.22). As regards the
sector, 31 nurses (25.5%) were allocated to medical
and surgical clinics; 29 (23.8%) belonged to adult,
neonatal and/or pediatric intensive care units; 10
(8.4%) worked in emergency care; nine (7.4%) in
pediatrics; eight (6.6%) belonged to the gynecology
and obstetrics sector and 34 (28.3%) to the other sectors investigated: orthopedics, dermatology
and immunology, psychiatrics, neurology, coronary
unit, infectious diseases, outpatient clinics, hematology and liver transplantation.
Concerning the occurrence of occupational
accidents involving exposure to potentially contaminated biological material among nurses, 65
(53.8%) were victims. Sixty-three (52.1%) involved
piercing-cutting material and (18.2%) exposure of
the mucosa and/or non-intact skin. It should be
highlighted that 50.5% of the nurses at the teaching hospital affirmed they had been victims of occupational accidents with piercing-cutting material,
against 56.7% at the smaller establishments.
The results show that 81.4% and 92.9% of the
victims at the teaching hospital and smaller establishments, respectively, notified the events. Among
the justifications for not reporting, two nurses indicated that they did not consider notification necessary and two that they did not consider the occupational accident they were victims of as dangerous;
two did not notify due to forgetting or the stress
the accident caused and one justified the delay in
returning to the responsible units.
The vaccination schedule for hepatitis B was
complete in 97.5% of the nurses, but 46.2% of the
nurses at the teaching hospital indicated not having
the recommended immune response and 26.4%
did not know the response. At the smaller establishments, 36.7% indicated not knowing about
the presence of the anti-HBs antibody and 40.0%
could not provide this important information.
The data revealed that 44.0% and 53.3% of the
sectors at the teaching hospital and at the smaller
establishments, respectively, did not change the
piercing-cutting material collector after one-third
had been filled.
Concerning the participation in training about
standard precautions, 87.9% of the nurses at the
teaching hospital and 80.0% at the smaller establishments affirmed they had participated in institutional training. Nevertheless, 96.7% of the nurses
at the smaller establishments indicated the desire to
participate, against 77.7% at the teaching hospital.
No statistically significant difference between the groups was found regarding the accident occurrence and notification (p=0.791 and
p=0.427); knowledge about the immune response
(p=0,379); change of the container (p=0.372) and
training about standard precautions (p=0.158).
As regards the desire to participate in training,
a statistically significant difference was verified
(p=0.014), as nurses working at the smaller establishments indicated greater desire to participate (Table 2).
Acta Paul Enferm. 2014; 27(3):280-6.
283
Table 2. Occurrence and notification of accidents involving
biological material according to piercing-cutting material,
immune response, container change, participation and desire to
participate in training
Teaching
hospital
n(%)
Smaller
establishments
n(%)
Yes
46(50.5)
17(56.7)
No
45(49.5)
13(43.3)
Yes
35(81.4)
13(92.9)
No
8(18.6)
1(7.1)
Variables
p-value
Accident with piercing-cutting material
0.791*
Accident reporting
0.427**
Knowledge immune response
Yes
24(26.4)
7(23.3)
No
42(46.2)
11(36.7)
Unknown
24(26.4)
12(40.0)
1(1.0)
-
Yes
51(5.0)
14(46.7%)
No
40(44.0)
16(53.3)
Yes
80(87.9)
24(80.0)
No
9(9.9)
6(20.0)
Did not answer
2(2.2)
-
Yes
70(77.7)
29(96.7)
No
21(22.3)
1(3.3)
Did not answer
0.379*
Change of containers
0.372*
Participation in training
0.158*
Desire to participate in training
0.014**
*Application of Pearson’s Chi-square test **Application of Fisher’s exact test
Discussion
The research findings are important to compare the
occurrence of occupational accidents involving exposure to potentially contaminated biological material in different establishments.
No significant difference was found in the occurrence and characteristics of the occupational accidents with regard to the establishments studied.
As to the training about standard precautions, no
statistically significant difference was verified, despite the larger proportion of nurses who participated at the teaching hospital. Nurses from the
smaller establishments demonstrated greater desire
to participate in updated about the theme, with a
statistically significant difference.
The sociodemographic analysis results are
demonstrated in other studies(19) and show that
nursing is still a predominantly female profes-
284
Acta Paul Enferm. 2014; 27(3):280-6.
sion, with ages below 40 years. Most of the nurses (52.40%) had some kind of specialization,
which is possibly associated with the teaching
hospital, which needs to attend to different
highly complex specialties.
As regards the occurrence of occupational accidents with piercing-cutting material, the same proportion was found in other studies,(19) which may
be related with the number of invasive procedures
nurses perform, such as venipuncture, serum therapy, collection of laboratory tests, capillary glucose,
among others.(20)
What non-reporting is concerned, the justifications that they consider reporting unnecessary or
attribute a low level of danger to the accident are
in accordance with other findings.(20) It is known
that the risk of catching the HCV virus after occupational exposure ranges between 1.8% and 0.3
to 0.5% for the HIV virus in cases of percutaneous
exposure. As for the hepatitis B virus, these percentages range between 6 and 30%.(21) Hence, the need
to report the accident and monitor the victim for
six months after the exposure is highlighted, including serology tests and correct completion of the case
evolution in SINAN NET.(7)
The vaccination schedule for hepatitis B and the
lack of knowledge about the antibody is also in line
with the research. In one study, it is indicated that,
although 99.8% of the victims indicated a complete
schedule for hepatitis B, only 40% referred the presence of the anti-HBs antibody, while 16.1% indicated no response, 18.5% that they did not take the
test and 20% did not complete this important information.(6) The results about the change of the piercing-cutting material collector differ from guidelines
for health establishments and encourage the proposal
of prevention and intervention measures.(22)
As regards the participation in training about
standard precautions, the desire to participate in both
groups of nurses was considerable, arousing reflections
about the impact of the previously proposed training. It should be highlighted that the occurrence of
accidents involving biological material in the research
groups drive towards the formulation and implementation of prevention and control measures, as more
than half of the nurses reported having suffered at least
one type of exposure to potentially contaminated biological material in their professional career. Study variables related to the occurrence of accidents, such as the
presence of the anti-HBs antibody and the change of
collectors lead to the conclusion that important safety
measures are not being practiced.
In a study involving 1444 Chinese nurses, it was
revealed that only half had received training about
standard precautions, and 98.2% expressed the desire to receive training.(5) In a study developed in
Jamaica, nurses and physicians wanted to participate in training, as well as qualification related to
the control of healthcare related infections.(8)
Professional education based on the principles and
reasons for the monitoring of safety practices are critical elements of standard precautions, as they facilitate
the correct decision process and promote adherence.
(23)
As studies reveal that training is directly related
with nurses’ adherence to standard precautions,(5,9)
continuous training of the workers is suggested with a
view to the adherence to safety measures.
Simply offering training is not sufficient though,
as studies evidence that knowledge about the standard precautions remained below desirable levels,
even after training, which reinforces the need for
evidence-based training contents and forms.(24) Even
after training, the study reveals that only 47% of the
workers considered the risk of body fluid droplets in
the eye mucosa a possible source of contamination,
only 63% understood the basic concept of standard
precautions and only 53.24% perceived the need to
use a mask in the physical examination of patients
with respiratory symptoms.
A multimodal strategy by Brazilian health agencies
to achieve adherence to hand washing indicates that a
set of actions is needed to overcome different behavioral obstacles and barriers. The institutions need to
guarantee the infrastructure needed to permit the correct practice of the procedure and provide training and
continuing education with assessment and feedback of
the data related to the workers’ practice, perception and
knowledge about the theme.(25)
The same source indicates that, to achieve adherence to the standard precautions, an environment
needs to be created that facilitates the professionals’
sensitization to patient safety, so as to include active
participation at the institutional and individual level.
A review of factors that influence adherence indicates
that variables like the organizational safety climate,
perceived obstacles, professional degree, care delivery
to a smaller number of patients, risk personality and
self-efficacy should not be ignored.(26)
Conclusion
Accidents involving exposure to biological material are
frequent. Although the professionals reported having
received training about standard precautions, there
was a great desire for reinforcement on the theme.
Collaborations
Valim MD participated in the conception of the project, analysis and interpretation of the data, writing of
the article and relevant critical review of the intellectual
content. Marziale MHP participated in the conception
of the project, analysis and interpretation of the data,
writing of the article, relevant critical review of the intellectual content and approval of the final version for
publication. Richart-Martinez and Hayashida M participated in the analysis and interpretation of the data
and relevant critical review of the intellectual content.
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Original Article
Changes in Quality of Life after kidney
transplantation and related factors
Mudanças na qualidade de vida após transplante renal e fatores relacionados
Ana Elza Oliveira de Mendonça1
Gilson de Vasconcelos Torres1
Marina de Góes Salvetti1
Joao Carlos Alchieri1
Isabelle Katherinne Fernandes Costa1
Keywords
Perioperative nursing; Nursing
research; Renal transplantation; Quality
of life; Socioeconomic factors
Descritores
Enfermagem perioperatória; Pesquisa
em enfermagem; Transplante de
rim; Qualidade de vida; Fatores
socioeconômicos
Submitted
April 17, 2014
Accepted
May 26, 2014
Gilson de Vasconcelos Torres
Senador Salgado Filho Avenue, 3000,
Natal, RN, Brazil.
Zip Code: 59078-970
[email protected]
DOI
http://dx.doi.org/10.1590/19820194201400048
Abstract
Objective: To identify changes on quality of life after the effectiveness of kidney transplantation and verify the
influence of sociodemographic factors on quality of life.
Methods: This is a descriptive study with study with longitudinal design. Data were collected in a private place,
using the World Health Organization Quality of Life (WHOQOL-bref) validated and culturally adapted to Brazilian
Portuguese by WHOQOL-Group.
Results: aged up to 35 years (50.8%), mean age 38.9 years (SD=12.9), married (60.3%), with children
(51.8%). The sociodemographic factors did not influence these patients’ perception of quality of life. The
QoL improved significantly in all domains. The greatest change was observed in the general QoL, Physical
Domain and Social Relationship Domain. The domain that showed less variation after transplantation was the
Environment Domain.
Conclusion: This study examined the impact of the effectiveness of kidney transplantation on quality of life
quality of life of chronic disease patients. The results indicated that transplantation had a positive impact and
changed the perception of these patients.
Resumo
Objetivo: Identificar as mudanças na qualidade de vida após a efetivação do transplante renal e verificar a
influência dos fatores sociodemográficos na percepção da qualidade de vida.
Métodos: Trata-se de estudo descritivo com desenho longitudinal. Os dados foram coletados em local privado
utilizando a versão abreviada do instrumento World Health Organization Quality of Life (WHOQOL-bref),
adaptado e validado para língua Portuguesa por meio do Grupo WHOQOL.
Resultados: Observou-se neste estudo o predomínio de pacientes adultos jovens com idade até 35 anos
(50,8%) e idade média de 38,9 anos (DP=12,9). Os fatores sociodemográficos não influenciaram a percepção
de qualidade de vida dos pacientes. A qualidade de vida melhorou significativamente em todos os domínios.
As maiores mudanças foram observadas na qualidade de vida geral, domínio físico e domínio relações sociais.
O domínio que demonstrou a menor variação após o transplante foi o domínio meio ambiente.
Conclusão: Este estudo avaliou o impacto da efetivação do transplante renal na qualidade de vida de pacientes
com doença renal crônica. Os resultados indicaram que o transplante teve impacto positivo na percepção de
Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil.
1
Acta Paul Enferm. 2014; 27(3):287-92.
287
Introduction
The technological and scientific advances in transplantation have enabled thousands of procedures that benefit organ and tissue recipients worldwide. Transplantation benefits patients who need solid organs, tissue
and cells by means of the development and improvement of surgical techniques, inputs, equipment and
immunosuppressive drugs needed to this therapy.(1)
The number of kidney transplant performed increased
significantly, as the number of candidates.(2)
In certain situations these procedures are configured as the only resource for sustaining life.(1) However, this treatment option is not always available
for those who are waiting for an organ transplantation because it requires a donation.(2-4) According to
the Brazilian National Transplant Registry, in June
2013 there were 22,187 patients registered on the
waiting list for solid organ transplantation of these,
19,913 (89.75%) were waiting for a kidney.(5)
Kidney transplantation requires compatibility
between tissues obtained for the Human Leukocyte Antigen typing (HLA). While waiting for a
donor, the chronic renal disease patients have other
forms of Renal Replacement Therapy (RRT) allow
the maintenance of their life and also justify the increasing number of patients registered on the waiting list for a kidney transplantation.(3,4)
Renal Insufficiency (RI) and the complexity of
their treatment constitute a serious public health
problem worldwide, with social and financial burden resulting from increasing rates of young patients with renal function failure.(6) Thus, measurement of patients’ Quality of Life (QoL) after kidney
transplantation, is a relevant topic for many individuals who are on dialysis in Brazil and receive care
in one of the 696 dialysis centers registered in the
Nephrology Brazilian Society (NBS).(7)
Renal transplantation is the best therapeutic option for patients with chronic kidney disease. The
surgical procedure is relatively simple, and after the
transplantation important actions are necessary such
as the use of immunosuppressive drugs and the outpatient follow-up.(8) Therefore, for these patients the
clinical management, the evaluation of treatment results, and impacts on QoL are important issues.
288
Acta Paul Enferm. 2014; 27(3):287-92.
The aim of this study was to identify changes
on quality of life after effectiveness of kidney transplantation and verify the influence of sociodemographic factors on quality of life.
Methods
The study population consisted of all chronic renal
failure patients receiving outpatient treatment at a referral center for kidney transplant in northeastern of
Brazil. A total of 63 patients aged over 18 years were
included. Data were collected in two steps in order to
assess the perception of kidney recipients before and
after transplantation. In the first step transplant candidates enrolled on the waiting list were interviewed,
in the second stage, interview kidney transplantation,
respecting the minimum interval of three months
that was the necessary time for patient recovery and
return to his/her daily life activities. All patients were
informed about the objectives of the study and those
who agreed to participate signed the consent form.
This study was a descriptive study with longitudinal design from May 2010 to May 2013 that included a population of chronic kidney disease patients receiving outpatient treatment. The study was the only
public hospital that performs kidney transplantation
and provides specialized care for this population.
Data were collected in a private place, using the
World Health Organization Quality of Life WHOQOL-bref, validated and culturally adapted to Brazilian Portuguese by WHOQOL-Group.(9) This instrument consists of 26 closed questions t assess perceptions of QoL two general questions about health
and QoL related to physical, psychological, social relationships and environment domains.(10) Responded items evaluated are distributed on 5-point Likert
scale ranging from 1 to 5, with higher scores indicating better QoL. The sum of the scores obtained in
each domain varies from 4 to 20. This instrument is
easy to understand and its reliability was tested in patients with renal disease and it achieved a Cronbach
Alpha index of 0.88, so that confirming its applicability in this group of patients.(11)
Data were organized by using an electronic
spreadsheet (Microsoft Office Excel®) and then
Mendonça AE, Torres GV, Salvetti MG, Alchieri JC, Costa IK
imported into the SPSS (version 17.0) where they
categorized, processed and analyzed using descriptive and univariate statistics. Analysis of variance
(ANOVA) one-way, t-test and Mann-Whitney test
were performed. The level of significance was set
at p< 0.05.
Development of this study followed national
and international ethical and legal aspects of research in human.
Table 1. Associations between sociodemographic variables and
quality of life pre- and post- kidney transplantation
General QoL
Sociodemographic
Variables
n(%)
Pre-transplantation
Pos-transplantation
p-value
Mann Whitney test
Gender
Male
Female
39(61.9)
24(38.1)
0.920
0.769
32(50.8)
31(49.2)
0.692
0.066
25(39.7)
38(60.3)
0.470
0.446
32(51.8)
31(49.2)
0.195
0.494
38(60.3)
25(39.7)
0.989
0.257
31(49.2)
32(50.8)
0.776
0.717
49(77.8)
14(22.2)
0.693
0.264
Age
< 35 years
> 35 years
Marital status
Single
Married
Results
In total, 63 patients participated in the study. The sociodemographic profile of respondents revealed a male
predominance (61.9%) with mean age of 38.9 years
(SD=12.9), married (60.3%), with children (51.8%).
Most participants had up to 8 years of formal education and were not (90.4%) at the time of the study
period. Hemodialysis was the most used (96.8%) in
this group of patients and the average waiting list time
for transplantation was 1.9 years (Table 1).
The analysis of sociodemographic factors related to overall QoL before and after transplantation
showed that these factors (gender, age, marital status, children, formal education, time on dialysis
and on waiting list) did not influence these patients’
perception of quality of life.
For data analysis, the mean domain scores and
standard deviation (SD), were calculated in the two
steps (before and after transplantation)for comparison purposes. The analysis of the scores showed
that QoL improved significantly in all domains.
The greatest change was observed in the general QoL questions that assessed overall satisfaction
with QoL and health satisfaction. The domain that
showed less variation after transplantation was the
Environment Domain (Table 2).
Although the Student-t test showed significant difference comparing the median scores in
all domains of QoL, we observed a significant
variance in General QoL (p=0.038), Physical Domain (p=0.032) and Social Relationship Domain
(p=0.035), which reinforces these aspects of QoL
improvement after renal transplantation.
Children
Yes
No
Formal Education
< 08 years
> 08 years
RRT*
< 05 years
> 05 years
Waiting list time
< 2 years
> 2 years
*
Renal Replacement Therapy
Table 2. Quality of Life scores before and after kidney
transplantation
General Questions
and Domains
WHOQOL-BREF**
Median Score (SD)
Before
Transplant
After
Transplant
p-value
t-Test
ANOVA
8.57(2.01)
17.65(1.78)
*
<0.001
0.038*
Physical domain
9.94(2.10)
17.41(1.78)
<0.001*
0.032*
Phychological domain
12.71(1.90)
17.70(1.66)
<0.001*
0.064
Social Relation
domain
12.70(2.95)
17.27(1.83)
<0.001*
0.035*
Environmental domain
11.98(2.14)
14.39(2.24)
<0.001*
0.694
General QoL
*p<0.05; **WHOQOL-BREF= World Health Organization Quality of Life Bref
Discussion
In this study a predominance of young adult patients aged up to 35 years (50.8%) and the mean
patient age was 38.9 years (SD=12.9). This result
revealed a worrying statistic because of the early
development of kidney disease and its rapid progression in economically active young individuals.
Differently of our study findings, a research that
evaluated 107 chronic renal disease patients reported slightly higher age, the mean patient age
51.1 years.(12)
Acta Paul Enferm. 2014; 27(3):287-92.
289
In this study there was predominance of participants married (60.3%), with children (51.8%).
Similar results were found in study involving with
renal disease patients more than a half of were married or liv in a stable relationship (67.7%) and as
well as most of them had children (81.2%).(13,14)
The most frequent education level of respondents was less than 8 years of formal education
(60.3%). Different results were observed in another study including hemodialysis patients in
the southeastern region of Brazil in which great
part of respondents (48.6%) had completed high
school.(12) The difference in education level observed in this study reflects the social inequalities and the levels human development found
across Brazil.
Regarding occupational status, 90.4% of participants were not working during the study period.
Researches conducted with patients undergoing
chronic renal dialysis showed similar results with
regard to occupational status (80.0% of patients
were retire and only 6.7% were working).(13,15,16) In
another study, only 9.3% of respondents reported
some work activity, being identified as the main reason for not working the difficult to found a balance
between the time required for hemodialysis.(12) A
study that compared the quality of life of kidney
patients on dialysis and after transplantation found
that approximately 80% of those undergoing kidney transplantation are able to return to their professional activities after three months of transplantation, while the index for patients who remained in
dialysis treatment was less than 30%.(8)
The arrangements for replacement therapies of
renal function are divided into dialysis and renal
transplantation. The dialysis can be obtained by filtration of blood in the extracorporeal circuit that is
called hemodialysis (HD) or with the lining of the
abdominal cavity called peritoneal dialysis. Kidney
transplantation is the modality that was recently
made available to patients with chronic kidney diseases, the replacement of renal function by implantation of a healthy kidney.(17)
In Brazil there are about 100,000 patients on
dialysis and HD is the most widely used treatment to replace the renal function.(7) The high
290
Acta Paul Enferm. 2014; 27(3):287-92.
prevalence of HD was confirmed in our study,
participants (96.8%) was undergoing hemodialysis three times per week, while only 3.2% underwent peritoneal dialysis. Hemodialysis partially replaces renal function and, for this reason
patients enrolled in waiting list for kidney transplant can wait many years, since the treatment
keeps the nitrogenous compounds at levels compatible with healthy individuals and it removes
excess fluid from the bloodstream.(4,18)
Most patients remained five years or more in dialysis (50.8%). Divergent results were found in another study that reported a time interval from 1 to
5 years in the most dialysis.(19) Given these findings,
we highlight the need for early referral of patients
who start dialysis to be registered in waiting list for
kidney transplantation, especially because longterm dialysis may influence negatively the identification of a suitable donor and survival time of the
transplanted organ.(8)
The perception of overall QoL of patients
before and after transplantation was not influenced by sociodemographic factors, confirming
a result that corroborates other study that correlated sociodemographic factors and QoL after
renal transplantation.(20)
The comparison between the mean scores of
QoL domains before and after effectiveness of
transplant showed significant improvement in general QoL and in all evaluated domains, positive
impact of renal transplantation on patients’ perception. This improvement was more significant
in general QoL, physical health domain and social
relationships domain. Similar results were observed
in study that compared kidney transplant recipients
and wait listed patients.(21)
Study that assessed health-related QoL issues
in 262 renal transplant recipients showed that the
physical component was influenced by the presence hypertension and diabetes, factors such as
levels of creatinine and hematocrit, that improve
after transplantation.(22)
The Social elation domain assesses the patient’ degree of satisfaction relation to the time
spend with family and friends and also the support given by them. This domain showed a sig-
Mendonça AE, Torres GV, Salvetti MG, Alchieri JC, Costa IK
nificant increase in the average score after transplantation. A study that evaluated patients on
hemodialysis indicated that the domain of social
relations was considered very relevant for kidney patients because of needs and dependence
of support the course of the disease.(2,4) Another
study showed that social relationships influence
the perception of QoL and it affects health, welfare and susceptibility of the patient to deal with
the disease process, for this reason, the social relationship is configured as a space for exchanging experiences, potential development and social protection.(23)
The psychological domain reflects the results
of transplantation as the fears and emotions of
patients, demonstrating perceptions of coping
strategies in situations of distress.(24) The emotional aspects should be considered as important
indicators of health and QoL in chronic kidney
diseases patients, since the changes in lifestyle
imposed by the disease, treatment and progression of symptoms might limit patients’ daily activities and also cause negative effects on their
perception of QoL.(22,24-26) Other studies found
that psychological factors tend to improve after
transplantation.(21,25)
Although the environment domain has presented the lowest scores compared to other QoL
domains, it showed significant difference before
and after transplantation indicating improvements in this aspect. This result can be explained
in part by the safety and property conditions of
participants that usually do not change after
transplantation effectiveness. Study that evaluated the QoL of 120 renal patients using the
WHOQOL-BREF, obtained similar results in
relation to the environment Domain with lower
scores when compared with other areas.(9)
This results indicated that patients undergone
renal transplantation had improvements in all dimensions of quality of life improvement evaluated
by WHOQOL-BREF compared to before transplantation as confirmed by other studies.(3,8,25)
This study contributes to the research literature
on QoL chronic renal diseases patients submitted to
kidney transplantation. Recent research that exam-
ined the influence of health-related QoL issues in
patients undergoing renal transplantation reported
that QoL scores were able to predict mortality and
graft failure independently of sociodemographic
and clinical risk factors of the patients, therefore,
indicating the importance of QoL evaluation in this
group of patients.(27)
Conclusion
This study examined the impact of effectiveness
of kidney transplantation on QoL chronic renal
disease patients. The results indicated that transplantation had a positive impact, changing the
perception of QoL in patients. All domains of
QoL showed improvement after transplantation,
especially those related to the general QoL perception. Sociodemographic factors did not influence our group of patients so that indicating
that transplantation was the main reason that
explains changes in quality of life.
Collaborations
Mendonça AEO; Torres GV; Salvetti MG; Alchieri
JC and Costa IKF declare that contributed to the
project design, analysis and interpretation of data,
drafting the article, critical revision of the important intellectual content and final approval of the
version to be published.
References
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