international symposium: science and research in nursing

Masaryk University, Faculty of Medicine, Department of Nursing
and University Hospital Brno
INTERNATIONAL SYMPOSIUM: SCIENCE AND
RESEARCH IN NURSING
26th September 2014
CONFERENCE PROCEEDINGS
Brno
Czech Republic
2014
The Conference is dedicated to project Ministry of Health: IGA - NT 12078 Implementation of the Nursing
Interventions Classification (NIC) in Anaesthesiology -Resuscitation and Surgical Care".
© 2014 Masaryk University
ISBN 978-80-7013-574-7
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CONTENT
RISKS OF WOMEN’S AND GIRL’S REPRODUCTIVE AND SEXUAL HEALTH ............ 5
Archalousová Alexandra
THE CZECH RED CROSS AND ITS APPROACH TO EMERGENCY PREPAREDNESS13
Balarinová Lucie, Ivanová Kateřina, Tučková Dagmar
SPIRITUAL NEEDS SATURATION IN THE HOSPITAL ................................................... 23
Beharková Natália, Grebíková Magdalena
THE DIFFERENCE BETWEEN PROVIDING OF NURSING CARE TO PATIENTS
AFTER THE SURGERY WITH LAPAROTOMIC AND LAPAROSCOPIC METHODS .. 35
Dimunová Lucia, Fiľová Etela, Raková Jana
THE β RATING SCALE TESTING RESULTS OF THE SELF-SUFFICIENCY LEVELS IN
PATIENTS WITH MULTIPLE SCLEROSIS ......................................................................... 42
Frčová Beáta, Rapčíková Tatiana, Beňadik Juraj
IMPACT OF TREATMENT ADHERENCE THERAPY ON QUALITY OF LIFE OF HIV POSITIVE PATIENTS ............................................................................................................ 49
Frei Jiří, Sedláček Dalibor
THE QUALITY OF PATIENTS LIFE AFTER THE PERCUTANEOUS CORONARY
INTERVENTION .................................................................................................................... 59
Haluzíková Jana, Zvolánková Eva
QUALITY OF LIFE OF CLIENTS WITH CHRONIC WOUNDS OF THE LOWER LIMBS
.................................................................................................................................................. 68
Janiczeková, Elena,Virgulová Jana, Melichová, Anna
AWARENESS OF GRAVIDITY, CHILDBIRTH AND CONTRACEPTION AMONG
GIRLS AT THE AGE OF 16 – 18 ........................................................................................... 78
Kelčíková Simona, Mazúchová Lucia, Kamenská Gabriela
PAIN MANAGEMENT WITH THE USE OF 3N ALLIANCE IN PATIENTS WITH
CHRONIC WOUNDS - REVIEW .......................................................................................... 89
Koutná Markéta, Pokorná Andrea
NUTRITIONAL BEHAVIOR IN RELATION TO OVERWEIGHT IN POPULATION OF
SCHOOL-AGED YOUTH ...................................................................................................... 99
Kožuchová Mária, Bašková Martina
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NEWLY GRADUATE NURSE IN INTENSIVE CARE: THE TRANSITION SHOCK
FROM COMING INTO PRACTICE .................................................................................... 108
Knechtová Zdeňka, Burešová Jana
THE QUALITY OF CARE FOR FAMILIES OF CHILDREN WITH CEREBRAL PALSY .......... 117
Kučová Jana, Sikorová Lucie
NURSING INTERVENTIONS BEFORE INVASIVE CARDIOLOGY PROCEDURE ..... 126
Líšková Miroslava
IDENTIFICATION OF NEGATIVE EXPERIENCE AND RISK FACTORS POSTTRAUMATIC STRESS DISORDER OF WOMEN IN RELATION TO CHILDBIRTH ... 135
Mazúchová Lucia, Kelčíková Simona, Paráková Dominika
THE RISK OF FALLING IN OPHTHALMICAL NURSING ............................................. 145
Mesárošová Jozefína
THE PREVENTION OF SORRORIGENIC WOUNDS IN INTENSIVE CARE ................ 154
Pokorná, Andrea. Blatnerová Hana
NURSING INTERVENTIONS USED IN SURGICAL NURSING PRACTICE ................. 166
Pospíšilová Alena, Kyasová Miroslava, Juřeníková Pera, Surá Zdeňka, Mičudová Erna
SELECTED FACTORS AND THEIR IMPACT ON QUALITY OF LIFE AND LIFE
SATISFACTION IN PEOPLE WITH COELIAC DISEASE ............................................... 178
Raková Jana, Tomašková Silvia, Dimunová Lucia
MENTAL WORKLOAD OF THE PARAMEDIC PROFESSION ...................................... 187
Sihelská Dana, Šovčíková Eva
UKRAINIANS IN THE CZECH REPUBLIC AND THEIR KNOWLEDGE OF FIRST AID ........ 197
Stelmaščuková Jana, Beharková Natália
THE TOPICS OF BACHEloR THESeS AT THE DEPARTMENT OF NURSING,
FACULTY OF MEDICINE, MASARYK UNIVERSITY .................................................... 212
Strakova Jana, Beharkova Natalia
THE OPINIONS OF NURSING STUDENTS ON NANDA – NURSING DIAGNOSIS.... 218
Straková Jana, Saibertová Simona
IMPLEMETATION OF SEPSIS PREVETION GUIDLINES FOR NURSES INTO A
CLINICAL PRACTICE ......................................................................................................... 224
Streitová Dana, Zoubková Renáta, Vavrošová Jana
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THE INCIDENCE OF ONCOLOGICAL DISEASES IN CHILDREN'S UNIVERSITY
HOSPITAL WITH POLICLINIC BANSKÁ BYSTRICA IN THE PERIOD 2002-2012 .... 234
Šupínová Mária, Balátová Silvia
COMPETENCE OF ACADEMIC STAFF – PhD SUPERVISORS IN THE NURSING
STUDY PROGRAM .............................................................................................................. 244
Tučková Dagmar, Olecká Ivana, Juríčková Lubica, Ivanová Kateřina
THE EFFECT OF METABOLIC SYNDROME ON PSYCHE ............................................ 254
Vévodová Šárka, Kučerová Kateřina, Vévoda Jiří, Merz Lukáš
ATTENDANCE OF THE PUBLIC IN THE PREVENTION OF COLORECTAL CANCER
................................................................................................................................................ 263
Virgulová Jana, Frčová Beáta, Šupínová Mária, Janiczeková Elena
CONTACT WITH BEREAVED PERSONS IN NURSING PRACTICE ............................ 272
Zítková Marie, Grossová Klementová Renáta
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RISKS OF WOMEN’S AND GIRL’S REPRODUCTIVE AND SEXUAL
HEALTH
Archalousová Alexandra
Department of Nursing, Faculty of Social Science and Health Care, Constantine The
Philosopher University in Nitra, Slovakia
ABSTRACT
Background: The aim of the study was to determine the attitudes of girls and women towards
risk factors of reproductive and sexual health - selected symptoms, choice of contraception,
the beginning and the frequency of use of hormonal contraception as well as the initiation of
sexual activity.
Methods: The empirical research using qualitative and quantitative methods of data analysis
was conducted. There were 449 questionnaires and 50 recordings of conversations analysed.
The respondents consisted of girls and women aged 13-45 years.
Results: A hormonal contraceptive is the preferred choice of contraception and the beginning
if its use is most frequent within 16-18 years (53.50 %), in 15 years or less 44.61 %. The
average age of the first sexual intercourse is 16,6 and the most frequent response was in age
from 14 to 17 years, of which 10.58 % in age of 15 or less. The results of the empirical
research were compared with other national and foreign studies.
Conclusion: The results suggest that, although the Czech Republic is one of those betterevaluated countries in field of reproductive and sexual health (for example in the criteria of
low percentage of teenage pregnancy) there are serious risks at present. Those could be seen
in the form of an early initiation of sexual intercourse, a preference of long-term hormonal
contraceptives, use of hormonal contraceptives before the age of 18 or less, low awareness of
health and delegation of responsibility to girls and women in comparison with the male
population.
Key Words: reproductive health, sexual health, women, girl, care, and risk factors.
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INTRODUCTION
One of the sub-objectives of the presented issue was to define the terminological terms of the
risks of reproductive and sexual health. Within the general conception a risk factor means
anything that disrupts health of an individual. It could be any family burden, a way of life,
some of the living habits, professional activity, eating habits, the incidence of diseases and a
number of other circumstances. Risk factors in the context of the disease represent situations,
habits or other phenomena that increase the sensitivity of an individual to the disease or
injury. From the perspective of nursing they can be categorized into five areas: genetic
factors, age, physiological factors, health habits and environment (Žiaková, Boledovičová,
Vorošová, 2009, p.206). These factors usually are not direct cause of a disease. They don’t
have to be always found in an anamnesis. According to Petružela and Cibula the risk factors
are being identified mostly on the basis of epidemiological studies through determining the
relative risk for a defined sub-population of carriers of the surveyed factor. Relative risk
above 1,0 refers to a risk factor. A relative risk under 1,0 on the other hand means that the
factor that had been researched could be considered as protective factor (Cibula, D., Petružela,
L., a kol., 2009, p.91-2). According to Burrouchs and Leifer, human papilloma virus infection
as a result of premature sexual intercourse, having more sexual partners or sexual partners
with some disease of a genital tract were stated as direct risk factors for the rise of disease of
cervical cancer. Those factors were defined by the US National Cancer Institute and its Centre
for Cancer Research and the National Institutes of Health. (Leifer, 2011, p. 248-62).
Sexual and reproductive health. These two terms are being often mistaken. Each has got its
specifics. Law related to man and woman protects sexual and reproductive health.
Reproductive health. It has been stated by the World Health Organisation that the
reproductive health is based in care of reproductive processes, functions and system through
all stages of life. The term of reproductive health therefore implies that people are able to lead
a responsible, satisfying and safe sex life and that they have the capability to reproduce and
the freedom to decide whether, when and how often they are going to fulfil such ability. It
also assumes the right of men and women to information on safe, effective, affordable and
acceptable methods of fertility regulation in order to make them use their discretion and the
Right to the use of appropriate health care services. That will enable women to safe pregnancy
and childbirth as well as ensures partner couples best prospects that they will have a healthy
child(WHO, 1994, p.24). Sexual health. Sexual health is, according to the World Health
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Organisation, defined as “a state of physical, mental and social well-being and not merely as
the absence of disease or disorder in anything that concerns ones sexuality. The condition of
sexual health is a positive and a respectful approach to sexuality and sexual relationships and
the possibility of satisfying and safe sexual experiences that occur without forcing,
discrimination or violence. In order to achieve and maintain sexual health is essential to
respect, protect and fulfil the sexual rights of all involved persons” (WHO, 2006, p.9). Sexual
and reproductive rights. Sexual and reproductive rights protect the sexual and reproductive
health. An article 96 of the Beijing Platform for Action (1995) says that the human right to
equality and to dignity is the basis of these rights. Sexual and reproductive rights including
the rights on health care during maternity and family planning incorporate freedom and
entitlements associated with a number of established civil, political, economic, social and
cultural rights. Although reproductive and sexual rights are not interchangeable with each
other, reproductive rights are being one aspect of sexual rights as well as sexual rights are
being a part of reproductive rights. (Yamin, 2005, p.11). The study is based on the European
Parliament’s Report given in autumn 2013 that sets out the priorities for ensuring satisfactory
state of reproductive and sexual health of the population in the Member States of
the European Union. Among the countries there are significant differences. The reported
evaluation criteria in population health risk are an unwanted pregnancy, teenage pregnancy,
the risk of the spread of venereal infection the degree of responsibility of both partners. The
main goal of the study was to find out the attitudes of girls and women towards risk factors of
reproductive and sexual health – selected symptoms: the choice of contraception, the
beginning and the frequency of use of hormonal contraception and initiation of sexual activity
(EU, 2013, p.2-16).
METHODS
The empirical research using qualitative and quantitative methods of data analyses was
conducted. There were 449 questionnaires, 50 recordings of conversations analysed. Among
the respondents there were girls and young women aged 13 to 45 years. The examination
reveals of which outputs were included into the module Sexual and reproductive health of
girls and women took place in the framework of the project: Projekt 004PU-4/2011 (2011 –
2013) KEGA of a topic: “Multimedia technology in the preparation of midwives
(Multimediálne technológie v príprave pôrodnych asistentiek”, of the University of Presov in
Prešov in cooperation with the Silesian University in Opava. Simultaneously the outputs were
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published in details in the collective monograph of authors Andraščíková, Archalousová,
Galdunová, Rybárová, Schlosserová and Žutáková called A risk disposition in the
reproductive period of women. Project started at the beginning of the year 2011 and finished
in December 2013.
RESULTS
There was a rate of return of 89,80 % made by 449 answered questionnaires out of 500
distributed ones. Out of the 100 planned interviews, there were just 50 recorded. A
demographic character of the respondents was based on the criteria for a period of
reproductive and sexual health and it covered just the population of women and girls within
the region of North Moravia in the Czech Republic and from Prešov in Slovak Republic. The
respondents were pupils of elementary schools and students of high schools and the
universities. There were presented the selected results in relation to the choice of a type of
contraception and its preference, to start using hormonal contraception, to the beginning of
sexual activity among girls and young women of the region of North Moravia.
The hormonal contraception is being preferred (Chart 1). Majority of the respondents (53,50
%) started to use hormonal contraception from age of 16 to 18 and in the age of 15 and less
44,61 % (Chart 2).
Structure of answers "Out of these various types of anticonception, please choose
the one you prefer most."
Condom
Hormonal contraception
IUD
Cointus interruptus
No contraception
Other contraception
0,47%
18,22%
19,36 %
7,94%
4,21%
49,80 %
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Chart 1: Structure of answers "Out of these various types of anticonception, please choose
the one you prefer most."
Structure of answers - "When did you start using hormonal
contraception?"
1,89 %
44,61 %
53,50 %
15 years and less
16 - 18 years
19 years and more
Chart 2: Structure of answers "When did you start using hormonal contraception?"
The average age of the first sexual intercourse is 16,6 and the most frequent response was in
age from 14 to 17 of which 10,58 % in age of 15 or less (Chart 3, Chart 4).
Structure of answers "Have you already had your first sexual experience?
Yes, I have already had my first sexual experience.
No, I have not had my first sexual experience yet.
6,67 %
93,33 %
Chart 3: Structure of answers "Have you already had your first sexual experience?
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Structure of answers "When did you have your firts sexual experience? "
2,49%
7,22%
2,41%
1,21%
3,01 %
9,03%
30,09 %
21,07%
23,48%
13-14 years
17 years
20 years
15 years
18 years
21 - 23 years
16 years
19 years
25 years and more
Chart 4: Structure of answers "When did you have your firts sexual experience?"
DISCUSSION
The results of the empirical survey were compared with other national or foreign studies.
Frequency and a preference of the hormonal contraception were being quoted from the
foreign studies. For instance there were 46,1 % of 7 898 questioned students in California
using hormonal contraception in 2011. The survey results are similar and demonstrate the
widespread use of hormonal contraception. On the other hand the systematic survey of
adolescents aged from 13 to 19 made in Portugal found out that a condom is the most
commonly chosen method of contraception (ie. 76 % - 96 %) as well as a method of the first
choice in sexual intercourse (ie. 52 % - 69 %) (Mendes et al., 2012, p.3-12). The rate of
sexual activity of Portuguese adolescents is high (ie. 44 % - 95 %). The average age of the
first sexual intercourse is currently 15,6 years. This premature initiation of sexual intercourse
is associated with smoking and regular alcohol consumption (Mendes et al. 2012, p.3-12).
The empirical study, which was carried out from 2011 to 2013, shows the average age of the
first sexual intercourse of 16,6 years and the most frequent response of the first sexual
intercourse in the period between the age of 14 and 17.. Information and its quality play an
important role in acquisition of habits leading to sexual and reproductive health. In 2007-2008
there was a large study with students of the University College Campus, in the age group 15
10
to 26 years on the subject of information on reproductive and sexual health. The topic was the
information on reproductive and sexual health and the respondents were of the age group of
15 – 26 years.
75 % of respondents used Internet as the main source of the information on reproductive and
sexual health. The Internet has become the main source of answers to sexual health and
information associated with them. The Internet is also connected to gaming (72 % of
respondents), chatting (67 % of respondents), downloads (72 %) and others (Buhi et al., 2008,
p.101-11).
CONCLUSION
The results suggest that, although the Czech Republic is one of those better evaluated
countries in field of reproductive and sexual health (for example in the criteria of low
percentage of teenage pregnancy, the general availability of hormonal contraceptives), that
there are serious risks at present. Those could be seen in the form of an early initiation of
sexual intercourse, a preference of long-term hormonal contraceptives, use of hormonal
contraceptives before the age of 18 or less, low awareness of health and delegation of
responsibility to girls and women in comparison with the male population.
REFERENCES
ANDRAŠČÍKOVÁ, Š. a kol. Rizikové stavy v reprodukčním období života ženy. Prešov: Prešovská univerzita,
2013. 195 s. ISBN 978-80-555-0983-9.
BUHI, R.E. et al. An Observational Study of How Young People Search for Online Sexual Health
Information.2008, p.101-11. Dostupné z: http://www.tandfonline.com/doi/full.
BURROUCHS, A., LEIFER, G. Maternity Nursing: An Introductory Text. Philadelphia: Sanders Company.
USA, 2001. ISBN 0-7216-8970-1.
CIBULA, D., PETRUŽELKA, L. a kol. Onkogynekologie. 1. vydání. Praha: Grada Publishing, a.s., 2009, p.912, 616 s. ISBN 978-80-247-2665-6.
EVROPSKÝ PARLAMENT. Zpráva o sexuálním a reprodukčním zdraví a právech (2013/2040(INI). Výbor pro
práva žen a rovnost pohlaví. Dokument A7-0306/2013 z 26. září 2013, p.2-16. Dostupné z:
http://www.europarl.europa.eu/
LEIFER, G. Introduction to Maternity and Pediatric Nursing. St. Louis: Sanders, 2011. P.248-62. ISBN 978-14377-0960-5.
MENDES, N., PALMA, F., SERRANO, F. Sexual and Reproductive Health of Portuguese Adolescents. 2012,
26(1), p.3-12. Dostupné z: http://www.ncbi.nlm.nih.gov/pubmed/
YAMIN, A. E. (ed.). Učit se tančit: Zlepšování reprodukčního zdraví a dobrých životních podmínek žen
z hlediska veřejného zdraví a lidských práv („Learning to dance: Advancing women’s reproductive health
and well-being from the perspectives of public health and human rights“). Cambridge, Harvard University
Press. 2005, p.11.
.WHO Výbor pro celosvětovou politiku. Dokument o stanovisku ke zdraví, populaci a rozvoji pro potřeby
mezinárodní konference o populaci a rozvoji („Position Paper on Health, Population and Development for
the International Conference on Population and Development“). Káhira 5 – 13. září 1994, s. 24, odst. 89.
11
WHO. Definice sexuálního zdraví: Zpráva z technických konzultací o sexuálním zdraví („Defining sexual
health: Report of a technical consultation on sexual health“). Ženeva, 2006, s.9.
ŽIAKOVÁ, K., BOLEDOVIČOVÁ, M., VOROŠOVÁ, G. a kol. Ošetřovatelský slovník. Martin: Osveta,
2009,p.206. ISBN 978-80-8063-315-8.
CONTACT AN AUTOR
Doc. PhDr. Alexandra Archalousová, PhD.
Department of Nursing, Faculty of Social Science and Health Care, Constantine The
Philosopher University in Nitra, Slovakia
Kaskova 1, 949 74 Nitra, Slovakia, Europe
e-mail: [email protected]
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THE CZECH RED CROSS AND ITS APPROACH TO EMERGENCY
PREPAREDNESS
Balarinová Lucie, Ivanová Kateřina, Tučková Dagmar
Balarinová, L.: Faculty of Health Sciences, Palacký University in Olomouc
Ivanová K, Tučková D.: Depatrment of Social Medicine and Public Health, Faculty of
Medicine and Dentistry, Palacký University in Olomouc
ABSTRACT
Background: Risks of modern society and emergency of the last years remind us significance
of crisis management. National Red Cross and Red Crescent Societies participate on crisis
management as well. But current and systematically researched data about the Czech Red
Cross (CRC) emergency preparedness are not available. The aim of the article is to present
research design of the CRC emergency preparedness for emergencies.
Methods: Research design is designed to bring basic data overview related to the Czech Red
Cross emergency preparedness. The research methodology is based on the main research
question: What is the Czech Red Cross preparedness for emergencies? The research question
is determined into four groups: the Czech Red Cross emergency management authorities, the
Czech Red Cross coordination during emergency, use volunteering of the Czech Red Cross
during emergency, internal communication channels of the Czech Red Cross during
emergency. The research was carried out in three successive stages [1] preliminary research
carried out on regional level, [2] research on the Czech Republic level, [3] examples of real
emergency preparedness. Respondents were directors of the Czech Red Cross branches. The
research method of the first stage was description and comparison, focus group in the second
stage, and case study in the third stage.
Results: In the first stage, the CRC Regional Association in Olomouc region was mapped and
verified determination of the CRC emergency preparedness. The respondents recommended
an interview as a technique of the next research and came with a recommendation for bringing
"an example of good practice“. The second stage brought a suggestion of schema of the CRC
emergency preparedness tools. The case study of the CRC emergency preparedness during
floods in the Mělnicko region (2013) will be the result of the third stage.
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Conlusion: Research design is designed to bring basic data overview related to the CRC
emergency preparedness.
Key Words: emergency/crisis situation, the Czech Red Cross, emergency preparedness
INTRODUCTION
The Czech Republic belongs among region which are regularly afflicted by emergencies
both lesser extent (traffic and other accidents, fires, tornadoes, accidents in the mountains or
water surface etc.) and wider extent which include mainly floods.
The subject of our research is represented by three major research fields: emergency, the
Czech Red Cross,
emergency preparedness. PICo (search strategy) was chosen for literature research. This
search strategy is recommended for qualitative research (www.library.curtin.edu.au, 2014). It
led to the clarification of key words and research areas. P (population - populace) – red cross,
red crescent, I (Phenomena of Interest) - emergency preparedness, crisis preparedness, C
(context) - emergency, catastrophe, flood, disaster, calamity, crisis situation. The searching
was made in databases available on the ground of Palacký University in Olomouc: PubMed,
EBSCO, SCOPUS, scholar google. We searched for resources from 2005 to keep the
information updated. Only three recourses were the result of the searching strategy and that is
why we draw on methodologies and publications available on the official website of the
International Federation of Red Cross and Red Crescent Societies in the discussion.
Mankind has always had to contend with a variety of adverse effects which are accompanied
by words such as "crisis" and "disaster." The word „crisis“ was common expression of
antique philosophers, physician or historians. Its original meaning was perceived as "The
decisive moment of conflict with the enemy, natural elements, illness“(Antušák, 2013, p 11).
The "disaster" can be viewed from multiple perspectives.
We can find basic classification according to causing cause on natural (unforeseen, expansive
natural phenomenon) or anthropogenic (caused by human activity or society) (Antonová,
2010, p 12). Experts disagree on the threshold of the minimum number of casualties and
extent of damage. According to UN, it can be regarded as a disaster event, where at least 10
victims of life and at least 100 victims affected by the disaster, a state of emergency is
declared or international assistance is requested by the local government (United Nations,
2008, p 80).
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National Red Cross and Red Crescent Societies provide help not only during catastrophe but
during lesser extent emergency which we can consider as emergency. Baštecká (2005,
according to Štětina et al, 2000, p 15) states three types of emergency. The first of them is
'collective misfortune limited ". It is emergency with maximum of 10 affected or injured. The
emergency is solved with help of local sources. "Bulk extensive disaster" has minimum of 10
and maximum of 50 affected. Emergency, alarm and trauma plans are activated during stated
emergency type. The last stated type is „catastrophe“. Víšek (2012, p 11) in his book
distinguishes three type of emergencies – „everyday events, catastrophes, crisis (emergency)
and armed conflict or war“. In the Czech Republic, the stated situation are defined by the Act
§ 2. b) of Act no. 239/2000 Coll., the integrated rescue system and emergency conditions
defined in § 2 point. b) Act. 240/2000 Sb., on crisis management).
In the Czech Republic, an integrated rescue system, which includes not only professional
rescuers (fire brigade, police, emergency medical service, etc.) but n on-profit organizations
just like the Czech Red Cross (§ 4 of Act no. 239/2000 Coll., The integrated rescue system)
has been implemented.
The Czech Red Cross is one of the national organizations of the International Red Cross and
Red Crescent society. It follows basic principles of the Red Cross and Red Crescent.
(officially adopted in 1965 in Vienna): humanity, neutrality, impartiality, independence,
voluntary, unity and worldwide repute which are considered as values and rules of all
members and volunteers of the Red Cross and Red Crescent to carry out the humanitarian,
social, health and health education activities (Jukl, 2010, p 1). The Czech Red Cross is
organization working on voluntary basis. 75 separately functioning CRC Regional
Association (CRC RA) are currently established in the Czech Republic (1. 1. 2013). In each
region, there is one CRC RA which acts as the so-called authorized CRC RA dealing with
issues and events with regional impact. The activities of all Local Societies are guaranteed by
the Czech Red Cross headquarters resided in Prague (CRC, 2013, p 44). One of the tasks of
the national Red Cross and Red Crescent is to provide help to victims of emergency and
catastrophe. The CRC has the stated task declared by documents, e.g. Act no. 126/1992 Sb.,
on the protection of the emblem and name of the Red Cross and the Czechoslovak Red Cross,
and in § 7 of the Red Cross.
Measures we implement to reduce the unwanted effect of emergencies and crisis effects we
can determine with the term emergency preparedness. We can understand the term emergency
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preparedness as a set of organizational, methodological and material-technical measures
carried out mostly by the organization's leadership in accordance with applicable legal
standards, crisis plan of the organization and the current state of crisis around the organization
(Antušák, 2013, p 13).“ The international federation of the Red Cross and Red Crescent
perceives emergency preparedness as a timely preparation of trained and organized
volunteers, maintaining the necessary emergency supplies, optimizing logistics and
communication (IFRC, 2010, p 13). We can perceive emergency preparedness of the CRC in
two levels a) central level, b) local level.
It is Humanity Fund on the central level which is determined for financial help. Emergency
Response Unit of Czech Red Cross is ensured personally on the central level. It is organized,
if it is needed flexibly a assembled a group of experts, members and volunteers of the Red
Cross focused on providing the Czech Red Cross personnel humanitarian aid abroad and in
the Czech Republic and on other tasks in accordance with the Articles of Association of the
Czech Red Cross. We can determine as a central way of help any specific project incurred to
the event, e.g. „A song for water“, benefit concerts (www.ukt.cervenykriz.eu, 2014).
The Czech Red Cross proceeds from the availability of forces and means each territorially
competent CRC RA on the local level. The CRC humanitarian units are groups of the CRC
members at each CRC RA and they are prepared for providing psycho-social help, medical
assistance, humanitarian help including care of evacuated persons. Structure of the CRC
humanitarian units is currently being revised. Variability of the CRC Humanitarian units was
evident during last flood events and there will move from the model of at least 21 members of
the CRC system to multi-stage system of the CRC Humanitarian units taking into account the
availability of forces and resources of each CRC RA. We can determine as a next way of local
help collection of material aid and distribution of material aid from the Czech Red Cross
humanitarian warehouses (www.cervenykriz.eu, 2014).
National Red Cross Society is aware of the timeliness issue and constantly makes steps in the
CRC emergency preparedness (new directives, policies crisis preparedness etc.) Nevertheless,
we consider the problem that we have failed to find current and systematically examined data
on the CRC emergency preparedness.
The focus of research is also based on practical experience when one of the authors is longterm a member of the CRC Central Crisis Team and since 2009 she has been actively
involved in the coordination of the CRC help in emergencies. The research topic directly
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follows Strategy 2020 of International Federation of the Red Cross and Red Crescent.
Strategy 2020 (IFRC, 2010, p 11) – saving lives, changing minds contains of three strategic
aims and one of the aims is: save lives, protect livelihoods, and strengthen recovery from
disasters and crises
The fact that there do not exist the valid data and variability of the CRC unit emergency
preparedness in practice was the inspiration for complex research in three follow-up phases.
The aim of the paper is to present the second research phase of the CRC emergency
preparedness in emergency.
METHODS
The main research question is: „What is emergency preparedness of the CRC in the Czech
Republic? “ The question was specified for each research phase: I. phase – „What is the CRC
emergency preparedness in the Olomouc region?“ II. phase – „What is the CRC emergency
preparedness in the Czech Republic?“ III. phase – „What was the CRC emergency
preparedness during specific emergency?“ The proposed research methodology is based on
the methods of description, comparison, analysis and case study methods. We decided to
make the research in three consecutive stages with the use of qualitative research.
I. PHASE – preliminary research on regional level
The first phase was carried out in the Olomouc region. It involved a pilot study and a
preliminary research to verification research tool for nationwide use. The pilot study involved
an assessment of semi-structured interview proposal by two expert of the CRC (president of
the CRC, and chairman of CRC RA) and verification if the research can be carried out on the
chosen population sample.
The target group of the research were persons on the position of Director of the CRC RA
Office. The preliminary research was carried out from March to December 2012 with using of
verified individual semi-structured interview (containing four themes according to the above
determination of emergency preparedness. It should give an answer for the research question.
One part of the phase was to address the respondents when all five Director of the CRC RA
Office agreed. The interview took in average 60 minutes.
II. PHASE – research on the nationwide level
Conducting of the second stage of the research was affected by floods which hit in June 2013
a part of the Czech Republic. The interviews with Director of the CRC RA Office in the
17
Czech Republic was planned to be carried out from June to September 2013 using a validated
semi-structured interview from the I. research phase. Research conducting was made
impossible by two circumstances. A deployment of one of researcher, Deputy Commander of
the Czech Red Cross Central Crisis Team, to coordinate of the CRC help in the Mělnicko
region and employment of respondents (Directors entrusted CRC RA) for the solution of
actual flood situation.
The research results would be confirmed by the verified semi-structured interview on the
nationwide level and extent to other data current only at the time of the research. It was
dropped from the attending of authorized CRC RA on the basis of stated circumstances and
after a consultation with the CRC experts. The research team, in co-operation with the CRC
leadership, was offered by presence at a workshop in October 2013 which was solely intended
to the target research group, Directors of authorized CRC RA. Individual semi-structured
interview was replaced with group interview research method. The target group was
maintained but origin research question of the II. research phase „What is the CRC
emergency preparedness in the Czech Republic?“ was specified to „What are the CRC
emergency preparedness tools?“
The workshop was realized in October 2013. The target group, Directors of authorized CRC
RA, was invited to this workshop. Directors of authorized CRC RA hit by floods 2013 spoke
in the afternoon section. The research researcher followed their presentation with the group
interviews. We perceive focus group research method according to specification by David L.
Morgan (2001); it is a group with the certain subject of interest – focus. According to
Miovský (2006, p 175) the focus can be a certain topic or general field. In our case it comes
about the CRC emergency preparedness tools. The group consists of 12 Directors of
authorized CRC RA and it was divided into the three group in four people. The aim of the
groups was description of emergency preparedness tools.
Moderators (research researcher and the CRC expert) guided a group discussion and observed
the mutual consensus. Three proposals schemes of the CRC emergency preparedness was the
group outcome lasted over 90 minutes.
III. PHASE – case study
The last phase which is currently carried out is case study research method. Proposed research
question was „What is the CRC emergency preparedness during specific emergency?“ It was
18
specified within the third phase to „What was the CRC emergency preparedness during floods
2013 in the Mělnicko region? “
RESULTS
The second research phase was focused on the CRC emergency preparedness tools. Three
proposals schemes of the CRC crisis preparedness tools arise from focus group method.
 Scheme of the CRC emergency preparedness tools.
 Scheme of activation of the CRC emergency preparedness tools in case of state of
emergency.
 Scheme of communication of the CRC emergency preparedness tools in the duration of
emergency.
„The CRC emergency preparedness tools“ were determine, and these are CRC RA, Fire units
CRC RA, authorized CRC RA, Fire units of CRC RA, the CRC Central crisis team, CRC RA
crisis staff, authorized CRC RA crisis staff, Central Crisis Staff of the CRC. There was
consensus in the group in case of schema the CRC emergency preparedness tools.
We do not mention proposals activation schemes and the CRC crisis communication tools
because the groups did not agree on one version. Discussed proposals will be used in the third
phase for comparison with a specified example from practice.
DISCUSSION
Primary answer during a catastrophe should be secured by local network of the Red Cross and
Red Crescent and authorized Red Cross and Red Crescent Society. High-quality preparedness
and reliability of regional branch and national societies of the Red Cross and Red Crescent is
the basic IFRC prerequisite for dealing with the increasing number of major disasters (IFRC,
2010, p 14). Emergency preparedness represents a field which should be provided on all
levels. It is about strengthening the resilience of individuals, communities, families and access
to health care and knowledge of how and what to do in emergencies (Veenema, 2013, p 24).
Organizations as the Red Cross and Red Crescent play no small part in this field. Annually
the International Federation of the Red Cross and Red Crescent provide help in average 30
million of affected people in the world and reaction for disasters represents the biggest area of
its activities (IFRC, 2011, p 12).
19
Fortunately, the Czech Red Cross still does not have to deal with challenges in a range of
world catastrophes (earthquake, Haiti 2010, earthquake and tsunami, Japan 2012). The Czech
Red Cross volunteers provided mostly help during smaller extent emergencies. But we can
hardly imagine that Director of the CRC RA would come with the words: I will not help you
– I do not have any volunteers, I do not have any money, we are unable to talk.
CONLUSION
The CRC leadership reflects the timeliness of emergency preparedness issue and accepts our
research. Currently they make steps to more effective, more efficient and economical
emergency preparedness system. We consider current mapping of the CRC emergency
preparedness as the implemented outcome for strengthen prevention or planned changes in the
CRC emergency preparedness. It is necessary to take into consideration that we consider the
research for laying the foundation in this issue. We do not bring exhaustive research of the
current CRC emergency preparedness using proposed research methods, which are
descriptive, comparative and analytical. We aim to gain basic data from piecemeal researched
area for what is the CRC crisis preparedness (or crisis preparedness of other NGOs in the
Czech Republic offering help to victims of emergency) considered (Smejkal, 2012, p 27).
Changes making and development of emergency was supported by floods which employed
the research target group (Directors of authorized CRC RA). They also arise the question
regarding to the CRC emergency preparedness tools which are subsequently solved by focus
groups.
The outcomes in terms of proposals schemes of the CRC emergency preparedness tools
showed as a result with possible implementation into the practice, e.g. included in the concept
of the individual authorized CRC RA. The example from the practice was used in the third
research phase for a comprehensive view of the CRC emergency preparedness and on the
target group recommendations – case study was used. The third phase is currently carried out
and it should contribute to the fulfilment of the main objectives of the research - it is the
acquisition of basic scientific data on the CRC emergency preparedness.
It is necessary to consider the chosen research design as a proposal for a research in
thematically similar issue. We consider consultation with the „authority“(in our case the
CRC) as essential, not only at the beginning, but also throughout the whole realization. A
research limit can be the fact that one of the authors is also a member of the CRC and
20
participates in the CRC emergency preparedness in practice. Gained data are far from
exhaustive and the field of the CRC emergency preparedness disserve deeper exploration.
Dedicated: Support of Human Resources in Science and Research
Research in Non-medical Healthcare at the Faculty of Health Sciences at Palacký University
Olomouc CZ.1.07/2.3.00/20.0163
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CONTACT AN AUTHOR
Mgr. Lucie Balarinová
Faculty of Health Sciences, Palacký University in Olomouc
Tř. Svobody 8, 771 11 Olomouc, Czech Republic, Europe
e-mail: [email protected]
22
New
SPIRITUAL NEEDS SATURATION IN THE HOSPITAL
Beharková Natália, Grebíková Magdalena
Department of Nursing, Faculty of Medicine, Masaryk University, Brno
ABSTRACT
Background: The unity of biological, psychical, social and spiritual elements is very
important in terms of the all-encompassing approach in nursing. The aim of the survey was to
identify ways of informing patients about the spiritual ministry in the hospital and
participation of the non-medical nursing staff in the saturation of the patients' spiritual needs.
Methods: Quantitative research – a questionnaire survey. The sample – non-medical nursing
staff (hereinafter NHCS, nurses responsible for general care with varied educational degrees
and work positions, nursing assistants). One hundred and ninety-four completed
questionnaires were analyzed. The results of the survey were processed via the Statistica 12
software. Microsoft Office Excel and Word 2007 were used for graphic presentation of the
results.
Results: 84.5 % respondents stated that they do not have a section in the documentation to
find out about the patients' spiritual needs. 34.5 % respondents inform the patients about
spiritual ministry in the hospital. 65.5 % respondents inform the patients in case they are
believers, ask for the information themselves, or do not inform them at all. Patients get
information about the religious services taking place in the hospital mostly from the notice
board in the ward corridor, as 46 % respondents stated. Spiritual needs are saturated at the
clinic mostly by the pastoral assistant and then by the hospital chaplain, as 88.6 %
respondents reported. 42.3 % of the survey participants cooperate with the pastoral assistant,
54.6 % nurses responsible for general care have never spoken to the pastoral assistant and 3.1
% respondents have no idea who she is. 64.9 % respondents stated they are likely to recognize
spiritual needs with the patients, 30.0 % respondents stated they are not likely to recognize
them. 46.4 % respondents communicate with patients about their spiritual needs with no
diffidence or self-consciousness. 14.0 % avoid such conversations because of feeling
uncertain and 3.1 % of the surveyed staff do not talk to patients about their spiritual needs due
to lack of time, feeling incompetent or because they are not believers.
Conclusion: The aim of the survey was to approach the issues of spiritual care in a health
facility and detect the participation of the NHCS in the patients' spiritual needs saturation.
23
General-care nurses often lack information necessary to provide complete nursing care
regarding all needs saturation. 52.6 % survey respondents reported they do not saturate the
spiritual needs within the nursing care namely for reasons of ignorance, lack of time, or
because the patients do not require this care.
Key Words: spirituality, spiritual care in the hospital, saturation of spiritual needs
INTRODUCTION
The holistic approach views a person as a unity of the biological, psychical and social. In
terms of the all-encompassing approach in nursing the spiritual element is also important.
„Spirituality pertains to the highest sense and goal in human life and it is of clinical
importance especially in situations when patients experience suffering due to a serious
disease or they are dying, also when deciding about further treatment.“ (Puchalski et al.,
2000, p. 129-137) Regarding the spiritual needs saturation the inner and outward saturation of
a spiritual need can be discussed. Very simply, the inner saturation can be perceived as
satisfying the spiritual needs by an individual him/herself. With outward saturation another
person satisfies the individual's spiritual needs. Perceiving one's own spiritual needs may be
difficult for some people. This is due to the difficulties in defining one's spiritual needs, on the
one hand, because for lay people these are often associated with the act of „believer/nonbeliever“, and further due to belonging to transcendent values. Nursing staff should have
basic knowledge about spiritual needs, spiritual health, spiritual decompensation, spiritual
pain. An integral part of the spiritual needs saturation area skills is the ability of the healthcare worker to identify a spiritual need of an individual, to choose an appropriate nursing
intervention and to contact the spiritual care provider. Team work is therefore necessary here.
The nursing staff are an important link in the spiritual needs identification who, within their
provision of health-care/nursing care identify the spiritual needs and then provide or mediate
the provision of spiritual care. Direct provision of spiritual care is done by the hospital
chaplains, pastoral assistants and volunteers. Family members and friends of the individual
play also their important role. The aim of the survey was to identify the way of informing the
patients about the spiritual ministry in the hospital and the participation of the non-medical
nursing staff in the patients' spiritual needs saturation. We supposed that more than 75 %
respondents would state that in their nursing documentation they do not have a place, a
„section“ for finding out about the patient's spiritual needs. We supposed that more than 25 %
respondents provide the patients with information about the options of spiritual ministry in the
24
hospital. Another premise was that more than 25 % of all replies would state that the patients
were informed about the religious services taking place in the hospital mostly by means of the
notice board in the ward/clinic corridor. From the spiritual care provision we supposed that
more than 75 % respondents know who provides spiritual care to patients at their clinic. We
also verified the premise that fewer than 50 % respondents would state that they co-operate
with the pastoral assistant regularly or as required. We were also interested in the respondents'
subjective evaluation of communicating with a patient about their spiritual need; we supposed
that fewer than 50 % respondents would state they talk with patients about spiritual needs
with no diffidence or self-consciousness. As for the respondents' own spiritual dimension, we
supposed that fewer than 50 % respondents would be able to fully describe and saturate their
own spiritual needs.
METHODS
The quantitative research was realized by means of a questionnaire of our own construction.
The structure of the questionnaire is derived from general recommendations for questionnaire
construction. The introductory section of the questionnaire included contact items to induce
cooperation and introduce the topic, as well as instruction for completion. The questionnaire
contained 18 questions with the functional, control, and filtration aims. The questions' concept
was of the open type (questions No. 2, 14), closed type (questions No. 1, 5, 8, 9, 13, 16) and
semi-open type (questions No. 3, 4, 6, 7, 10, 11, 12, 15, 17 and 18). The questions No. 1 - 3
asked for the respondent's identification data. Questions No. 4 – 7 evaluated the ward's
organization system. Questions No. 8 – 18 surveyed the spiritual care satisfaction by the
general-care nurse and her attitudes towards the topic stated. At the questionnaire's conclusion
some space was set apart for incidental observations. The sample of respondents included
non-medical nursing staff (general-care nurses with varied educational degrees and work
positions and nursing assistants). Consent to realizing the questionnaire survey in the health
facility was issued based on our request. The data collection term lasted from 23rd October
2013 to 20th December 2013 at pre-selected clinics of the internal medicine branch. One
hundred and ninety-four completed questionnaires were analyzed. The survey results were
processed by the Statistica 12 software. Graphic presentation of the results was processed by
Microsoft Office Excel and Word 2007 programmes. The survey results are presented in both
the absolute and relative frequencies.
25
RESULTS
Two hundred and fifty questionnaires were consented for distribution by the health facility for
the purpose of the research. From this number 239 questionnaires were distributed to the preselected internal medicine workplaces and 203 completed questionnaires were returned. Due
to incompleteness or faulty completion 9 questionnaires were excluded. 194 correctly
completed questionnaires were used for the processing. The overall return rate was therefore
85 %. Out of the total number of 194 respondents 96.9 % were women (i. e. 188) and 3,1 %
men (i. e. 6). Respondents with varied lengths of related work experience participated in the
questionnaire survey. There were 39.7 % respondents whose related work experience was
shorter than 5 years (i. e. 77), respondents with related work experience from 6 to 10 years
constituted 21.7 % (i. e. 42). 21.1 % (i. e. 41) respondents stated the length of their related
work experience in the interval from 11 to 20 years, and 10.8 % (i. e. 21) respondents marked
the length of 21 to 30 years. The lowest number, 6.7 % (i. e. 13) respondents stated the length
of their related work experience as 31 plus years. As for the education level, 45.9 %
respondents had finished a secondary nursing school, the general-care nurse branch, and 10.3
% respondents had graduated as nursing assistants; a higher specialized school, general-care
nurse branch, was stated by 21.7 % respondents. A university bachelor's degree was stated by
11.3 % respondents and a master's degree by 6.7 % respondents. 4.1 % respondents were still
studying. The resulting data about the achieved education is related to the age distribution of
the respondents and the qualifications requirements for performing the job of a general-care
nurse.
The survey results imply that 84.5 % (i. e. 164) respondents stated that they did not have a
„section“ set apart in their nursing documentation for identifying the patient's spiritual needs.
The option „believer/non-believer“ was indicated by 1.5 % (i. e. 3) respondents, „I require/do
not require spiritual care“ was indicated by 3.6 % (i. e. 7) respondents. 5.2 % (i. e. 10)
respondents indicated the option „I do not know“. „Another option“ was indicated by 5.2 %
(i. g. 10) respondents, namely 3 respondents stated that at their clinic the nursing
documentation section of „domestic rules“ serves to identify or approximate the patient's
spiritual needs, 3 respondents stated „various hospital services“, 2 respondents stated the
section „others“ and the remaining 2 respondents use for the above-mentioned purpose the
section „on call“ (see Table 1).
26
Table 1: Nursing documentation
Nursing documentation
Believer/non-believer
I require/do not require spiritual care
We do not have a documentation section
Do not know
Others
TOTAL
Absolute frequency
3
7
164
10
10
194
Relative frequency
1.5 %
3.6 %
84.5 %
5.2 %
5.2 %
100 %
112 (57.7 %) respondents stated they inform the patients about the spiritual care just in case
the patient asks for the information him/herself. Further, 41 (21.1 %) respondents stated they
inform the patients about the option of making use of the spiritual care during their
hospitalization if they assess the presence of such a need. Communicating this information
always at the reception of a new patient was indicated by 26 (13.4 %) respondents. The option
„only in case the patient stated s/he was a believer“ was indicated by 8 (4.1 %) respondents. 7
(3.7 %) respondents indicated a negative response. The expected result, where we supposed
that more than 25 % respondents provide the patients with information about the option of
spiritual care in the hospital, was verified as 34.5 % (i. e. 67) respondents inform the patients
about the spiritual care always at their reception or during the hospitalization if they assess the
presence of such a need. The remaining 65.5 % (i. e. 127) respondents inform the patients
only if the patients are believers, if they ask for the information themselves or they do not
inform them at all (Table 2).
Table 2: The information rate about the option of using the spiritual care
The information rate about the option of using the spiritual care
Absolute frequency
Relative frequency
Always at reception
During the hospitalization, if I assess the presence of such a need
26
41
13.4 %
21.1 %
Just in case the patient stated s/he was a believer
8
4.1 %
Just in case the patient him/herself asks for spiritual care
112
57.7 %
No
TOTAL
7
194
3.7 %
100 %
In relation to providing information about the religious service we were interested in the ways
of informing the patients. The respondents could indicate more responses. The option of
informing about the religious service by the general-care nurse was indicated 63 times (17.5
%), 19 times (5.3 %) the option of being informed by the doctor was indicated, 166 times
(46.0 %) the option of getting the information from the notice board in the corridor was
chosen. The option of learning from the ward operating regulations was stated 57 times (15.8
%), the hospital web pages 46 times (12.7 %). The option „don't know“ was indicated 7 times
27
(1.9 %). The option „other“ was chosen 3 times (0.8 %) where 2 respondents stated the option
of informing about the hospital religious service by means of an information leaflet in the
hospital room, and 1 respondent stated the option of informing through the pastoral assistant.
The expected result that more than 25 % of all responses would declare that the patients are
informed about the hospital religious service taking place mostly by means of the information
notice board at the corridor of the ward/clinic, has been confirmed (Table 3).
Table 3: Awareness of the religious service
Awareness of the religious service
From the general care nurse
From a doctor
From the information notice board at the corridor
From the ward operating regulations
From the hospital web pages
Don't know
Other
TOTAL
Absolute frequency
63
Relative frequency
17.5 %
19
166
57
46
7
3
361
5.3 %
46.0 %
15.8 %
12.7 %
1.9 %
0.8 %
100 %
The patients' spiritual needs are mostly saturated by the pastoral assistant; this option was
chosen 147 times (54.0 %), followed by the hospital chaplain who was stated 94 times (34.6
%). The option of the nurse responsible for general care was indicated 10 times (3.7 %), the
option „other“ was indicated twice (0.7 %), specifically, a priest was stated as the spiritual
care provider. The option „don't know“ was indicated 19 times (7.0 %). The expected result
that more than 75 % respondents would know who provides the spiritual care to the patients at
their clinic has been confirmed (Table 4).
Table 4: Spiritual care saturation
Spiritual care saturation
The hospital chaplain
The pastoral assistant
General care nurse
Don't know
Other
TOTAL
Absolute frequency
94
147
10
19
2
272
Relative frequency
34.6 %
54.0 %
3.7 %
7.0 %
0.7 %
100 %
106 respondents (54.6 %) have never spoken to the pastoral assistant. 82 respondents (42.3
%) stated the option „regularly“ or „cooperate with the pastoral assistant according to the
need“ and the remaining 6 (3.1 %) respondents stated the option „I don't know who s/he is“.
The expected result that fewer than 50 % respondents would state they cooperate with the
pastoral assistant regularly or according to the need has been confirmed (Table 5).
28
Table 5: Cooperation with the pastoral assistant
Cooperation with the pastoral assistant
Have never spoken to her/him
I cooperate with her/him regularly or according to the need
I don't know who s/he is
TOTAL
Absolute frequency
106
82
6
194
Relative frequency
54.6 %
42.3 %
3.1 %
100 %
In the questionnaire query focusing on identifying the respondents' feelings when leading a
conversation with a patient about their spiritual needs it was found out that 90 respondents
(46.4 %) speak to the patients about their spiritual needs with no diffidence or selfconsciousness. 71 (36.5 %) respondents have unpleasant feelings while conversing about the
topic but they listen to the patient and offer her/him mediation of the spiritual care. 27 (14.0
%) respondents feel uncertain and prefer to avoid the topics related to beliefs, religion and
spiritual needs. Another option was stated by 6 (3.1 %) respondents; specifically, 2
respondents stated they never speak to the patients about the spiritual needs, 2 respondents
stated they do not speak to the patients about their spiritual needs because of the lack of time,
1 respondent stated s/he does not see her/himself competent enough for this task and 1
respondent stated s/he does not speak to the patients about the spiritual needs since s/he is not
a believer. The expected result where we supposed that fewer than 50 % respondents would
state they speak to the patients about their spiritual needs with no diffidence or selfconsciousness has been confirmed (Table 6).
Table 6: Conversation about spiritual needs
Conversation about spiritual needs
With no diffidence or self-consciousness
I have unpleasant feelings but I listen to the patient and offer mediating
the spiritual care
I feel uncertain and I prefer to avoid the topics related to beliefs, religion
or spiritual needs
Other
TOTAL
Absolute
frequency
90
71
Relative
frequency
46,.4 %
36.5 %
27
14.0 %
6
194
3.1 %
100 %
30.9 % (i. e. 60) respondents can describe and satisfy their spiritual needs and 2.6 % (i. e. 5)
cannot satisfy them at all. 25.8 % (i. e. 50) respondents cannot express their spiritual needs in
words. Most respondents, 40.7 % (i. e. 79), state they have no spiritual needs. The expected
result that fewer than 50 % respondents would be able to fully describe and saturate their
spiritual needs has been confirmed (Table 7)
29
Table 7: Respondents' spiritual needs
Respondents' spiritual needs
I can describe them fully and I try to saturate them
I cannot express my spiritual needs in words
I cannot saturate my spiritual needs
I have no spiritual needs
TOTAL
Absolute frequency
60
50
5
79
194
Relative frequency
30.9 %
25.8 %
2.6 %
40.7 %
100 %
DISCUSSION
Spiritual care is considered an important part of the complex patient care provision in health
facilities. These issues are more and more often dealt with by experts as well as the lay public.
The published works and their contents focus more on specific patient groups (oncologic
patients, the elderly) or on hospice care. Less frequent are works focusing specifically on
providing spiritual care in health facilities. Mostly, they are chapters in monographies or
references to articles about spiritual topics on web pages. Currently, a trend of spiritual care
proliferation is indicated from the hospices to other health facilities and from a specific
patient group to all the others (Grebíková, 2014, p. 51). Since the issue of spirituality is an
intimate and individual one, provision of spiritual care in health facilities is often not
sufficient and the results of various surveys form an important part of spiritual care
development. A nurse is an integral part of the multidisciplinary team taking care of the
patient. S/he spends most time at the patient's bed, it is therefore necessary that they would be
able to identify the individual's spiritual needs properly and in time and intervene for them to
be saturated. Spiritual assessment and care was often recognized to be the nurse's role
(Edwards et al., 2010). Our survey implies that 84.5 % respondents stated they do not have a
„box“ in their nursing documentation set apart for noting down the patient's spiritual need,
which leads us to think about in what way and where the data related to the spiritual needs
area and acquired within the patient's anamnesis is kept. 10.3 % respondents stated they note
down the identified spiritual needs while the „boxes“ set apart for this purpose are not unified.
For a better clarity and accessibility of the acquired data, as well as respecting the patient's
personal data, it would be advisable to introduce a unified evidence procedure according to
the recommendations of the health facility. 34.5 % respondents inform the patients about the
options of spiritual care within the health facility, which can be viewed as non-satisfactory
result, since it points out the nurses' non-active approach in the area of spiritual needs
identification. A passive attitude of the nurses is further confirmed by the result of 4.1 %
respondents informing about the spiritual care just in case the patient is a believer and 57.7 %
just in case the patient asks for this care him/herself. Every patient should be informed about
30
the spiritual care within their acquaintance with the organizational schedule at the ward/clinic
during the time of their hospitalization, taking into account their health and the intimate
nature of the spiritual needs, at the beginning or during their hospitalization. The lasting myth
stating that spiritual care is just for believers is a malpractice even among the nursing staff
and it can contribute to the fact that the patient's spiritual need will not be identified properly
and in time. The survey results confirm this. 42.5 % respondents perceives spiritual needs as
related to religion and one's belief. A lot of people including nursing staff think that saturation
of believers' needs is concerned (Svatošová 2012, p. 23). Our results correspond to the survey
(Zítková 2009, p. 67) done in the same health facility where 17.6 % of the patients
hospitalized at the intern wards were informed about the spiritual care at their reception or
during the hospitalization and the remaining 82.4 % were not informed. In the survey
mentioned a difference was noted among the wards. The highest awareness of the spiritual
care was registered with patients hospitalized at the oncologic ward (44.8 % were informed,
55.5 % were not informed). In Ms Zítková's survey (2009, p. 86) statistically significant
difference was confirmed of the awareness of the patients hospitalized at the intern, surgical,
oncologic and the hospice-type wards. It confirms the assumption of a relation between the
patients' higher spiritual needs and the severity of their diagnosis and individual life contexts.
Some studies have revealed that the spiritual dimension intensifies when patients suffer from
severe and protracted illnesses (Strang et al. 2002, p. 49; Thorson & Powell 1990; Koenig et
al. 1999). In another study (Strang et al. 2002, p. 52) it was found out that in response to the
question about their opinions of patients' spiritual/existential needs, a majority (87 %) stressed
the importance of paying attention to these needs. There were no statistical differences related
to age, occupation or wards. However, only about 42 % of the respondents reported that staff
paid attention to spiritual needs in their own ward.
Various ways of informing the patients about the provided spiritual care in the form of a
religious service are chosen in the health facilities. 46 % respondents in our survey stated that
the information about the religious service taking place are communicated by means of a
notice board in the corridor. This information has the nature of public accessibility at the ward
while discriminating the patients with limited motion regime or patients who cannot leave
their beds. For better accessibility and ensuring awareness of the religious service taking place
in the health facility, or of the options and accessibility of the spiritual care for all hospitalized
patients it is advisable to provide the information by means of written communication in the
31
form of a leaflet or within the operating/organizational regulations at the rooms. In Ms
Zítková's survey (2009, p. 71-72) it was found out that 66.7 % respondents hospitalized at the
intern wards do not know about the religious service taking place, 19.6 % respondents know
about it taking place but do not take part in it due to their health, 13.7 % respondents know
about it taking place but do not need this type of care. Our survey implies that the spiritual
care at the intern wards of the health facility is provided by pastoral assistants, this option was
indicated by 54 % respondents. Spiritual care provided by the hospital chaplain was stated by
34.6 % respondents. The survey results imply that 7 % respondents do not know at all who
provides for the patients' spiritual needs at their clinic. 42.3 % respondents cooperate with the
pastoral assistant regularly or according to the need, 54.6 % respondents have never spoken to
him/her and 3.1 % respondents indicated the option „I don't know who s/he is“. The survey
results are non-satisfactory. According to Ms Zítková's survey (2009, p. 70) 10 % of the
hospitalized patients have met and talked to the pastoral assistant, 8 % stated just having met
him/her and 82 % of the respondents had no experience with the pastoral assistant. The
solution suggested by us is to raise the awareness of the current and newly hired personnel at
the wards of the options of spiritual care and communicating the information via posting it in
the nurses' room/in the check up room. Organizing a seminar with the pastoral assistant or the
hospital chaplain would be an advisable solution at a specific ward where this care would be
introduced to the nursing staff. This form would lead to better awareness of the nursing staff
and better accessibility of the spiritual care to all patients. 64.9 % respondents stated they are
likely to identify a patient's spiritual needs. 4.1 % respondents declared they were able to
identify a patient's spiritual needs and 30 % respondents indicated the option that they are not
likely to identify a patient's spiritual needs. 47.4 % respondents stated that spiritual care is a
part of the nursing care provided by them. 52.6 % respondents indicated the option that they
do not provide spiritual care. The reasons stated by the respondents were: „I am an atheist/I
am not a believer“, ignorance or insufficient knowledge of the spiritual care, lack of time, the
patient does not require this care. The Strang et al. (2002, p. 52) survey implies that 49 %
stated holistic care was applied on their own ward. Only two-thirds considered holistic care to
include spirituality. The questionnaire analysis implies that 65.5 % respondents assess the
patients' spiritual needs through a conversation. Other assessment forms were not stated by
the respondents. In relation to that we were interested in the respondents' feelings while
identifying the patients' spiritual needs. 46.4 % respondents communicates with the patient
about their spiritual needs with no diffidence or self-consciousness. 36.5 % experience
32
unpleasant feelings but they listen to the patient and offer mediating the spiritual care. 14 %
respondents feel uncertain and prefer to avoid the topics related to one's belief, religion and
spiritual needs. Most respondents, i. e. 40.7 % state they do not have any spiritual needs. The
inability of the nurses to describe and saturate their own spiritual needs leads us to think if
these nurses can describe and saturate the patient's spiritual needs. Ross (2006) based on a
synopsis study of surveys dealing with the spiritual issues states that spiritual care is
supported at places where nurses are aware of their own spirituality (Boutell and Bozett 1990,
Ross 1994, Harrington 1995, Taylor et al. 1995; Carroll 2001, Kuuppelomaki 2001, Stranahan
2001, Narayanasama et al. 2002).
CONCLUSION
The specific nature of spiritual needs places high demands on the communication skills of the
nursing staff. Knowledge of spiritual needs, communication skills, being aware of one's own
spirituality and the nursing worker's experience acquired with years of practice – those factors
contribute to identification of the patient's needs and mutually „easier“ conversation touching
the spiritual issues. It is essential for the spiritual needs saturation to respect the uniqueness of
each patient with their personal history and inner world into which one can penetrate only to
such an extent as the person allows them to (Svatošová 2012, p. 11). Openness to the holistic
approach and the unity of not only the biological, psychical and social but also the spiritual,
not being afraid of listening to the patient's spiritual need without feeling as performing a duty
or experience a pressure on one's person – those attributes will enable spiritual needs
saturation within the framework of providing complex nursing care.
REFERENCES
GREBÍKOVÁ, M. Uspokojování spirituálních potřeb v nemocnici. [online]. Masarykova univerzita Brno, 16th
April 2014. [vid. 2014-11-8]. Accessible from: http://is.muni.cz/th/395423/lf_b/Bakalarska_prace.pdf
EDWARDS, A. et al. The understanding of spirituality and the potential role of spiritual care in end-of-life and
palliative care in end-of-life and palliative care: a meta-study of qualitative research. [online]. In: Palliative
medicine. 2010, vol. 11, p. 753-770 [vid. 2014-11-8]. Accessible from:
http://pmj.sagepub.com/content/24/8/753 Process.pdf
SVATOŠOVÁ M. Hospice a umění doprovázet. 6. vyd. Kostelní Vydří: Karmelitánské nakladatelství, 2008. 151
p. ISBN 978-80-7195-307-4.
SVATOŠOVÁ M. Víme si rady s duchovními potřebami nemocných?. 1. vyd. Praha: Grada Publishing, a.s.,
2012. 112 s. ISBN 978-80-247-4107-9.
STRANG S., STRANG P. TERNESTEDT B. M. Spiritual needs as defined by Swedish nursing staff. [online].
Journal of Clinical nursing. 2011, vol. 11, p. 48-57 [vid. 2014-11-8]. Accessible from:
http://www.ncbi.nlm.nih.gov/pubmed/11845755 Process.pdf
VORLÍČEK J., ADAM Z. a kol. Paliativní medicína. 1. vyd. Praha: Grada Publishing, spol. s.r.o., 1998. 480 s.
ISBN 80-7169-437-1.
33
Dodatek č. 1 k dohodě o duchovní péči ve zdravotnictví mezi českou biskupskou konferencí a Ekumenickou
radou církví v České republice. [online]. 12th December 2011 [vid. 2014-11-8]. Accessible from:
http://www.ado.cz/kaplan/dodatek_1.pdf.
Dohoda o duchovní péči ve zdravotnictví mezi Českou biskupskou konferencí a Ekumenickou radou církví
v České republice [online]. Praha, 20th November 2006. [vid. 2014-11-8]. Accessible from:
http://tisk.cirkev.cz/res/data/008/001107.pdf?seek=1.
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OPATRNÝ A. Péče o existencionální a spirituální potřeby pacienta. [online].[vid. 2014-11-8]. Accessible from:
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službách)[online]. [vid. 2014-11-8]. Accessible from: http://www.zakonyprolidi.cz/cs/2011-372#cast4.
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Fully[online]. Journal of Paliative Medicine. 2000, year 3, issue 1. [vid. 2014-11-8], p 129 – 137. Accessible
from: http://online.liebertpub.com/doi/abs/10.1089/jpm.2000.3.129.
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p. 852-8862 [vid. 2014-11-8]. Accessible from: http://www.ncbi.nlm.nih.gov/pubmed/16879378
ZÍTKOVÁ M. Spirituální potřeby jako součást holistického přístupu k nemocným. [online]. Masarykova
univerzita Brno, 31st March 2009. [vid. 2014-11-8]. Accessible from:
http://is.muni.cz/th/38329/lf_m/Diplomova_prace.pdf.
CONTACT AN AUTHOR
Natália Beharková
Department of Nursing, Faculty of Medicine, Masaryk university
Kamenice 3, Brno 625 00, Czech Republic, Europe
e-mail:[email protected]
34
THE DIFFERENCE BETWEEN PROVIDING OF NURSING CARE TO
PATIENTS AFTER THE SURGERY WITH LAPAROTOMIC AND
LAPAROSCOPIC METHODS
Dimunová Lucia, Fiľová Etela, Raková Jana
Dimunová, L., Raková J.: Department of Nursing, Faculty of Medicine, Pavol Jozef Šafarik
University, Kosice
Fiľová, E.: Surgery clinic, Kosice-Saca Hospital
ABSTRACT
Background: Our aim was to determine differences in the effectiveness of nursing
interventions in patients after colorectal surgery performed by laparotomic and laparoscopic
procedure.
Methods: Quantitative research method of document content analysis. 60 medical records
were monitored during the first seven days of post-surgical care. We followed the differences
in surgical procedures, focusing on post-surgical care in 19 of nursing interventions. We
created a database of collected data and performed interventions through numeric codes. The
results were processed in SPSS 18.0 (Mann-Whitney U test).
Results: A statistically significant difference in favour of the laparoscopy was confirmed in
14 of nursing interventions, in case of one intervention there was a significant difference in
favour of laparotomy while in 5 interventions no statistically significant differences were
found. The most important interventions included: smaller amount of parenteral nutrition, less
frequent bandaging, shorter period of time needed for indwelling urinary catheter, fewer
laxatives taken, less dependence in hygienic care.
Conclusions: Our results confirmed benefits of laparoscopy in two thirds of surveyed nursing
practices. Total duration of patient hospitalization in a standard ward as well as in the
intensive care unit also proved to be in favour of laparoscopy.
Key Words: nursing care, nurse, colorectal surgeries, laparoscopy, laparotomy.
INTRODUCTION
Colorectal diseases are currently holding a prominent place on a list of civilization diseases.
Progress in the field of early diagnosis and treatment plays a crucial role in eliminating the
35
consequences of these diseases. Chirurgical surgeries performed by laparoscopic or
laparotomic surgical procedure represent one method of treatment of colorectal diseases.
Laparotomy is a surgical procedure involving a large incision through the abdominal wall in
order to gain access into the abdominal cavity. Based on the location and direction, we
distinguish between lengthwise, transverse and oblique incisions. When choosing the right
incision, it is important to consider factors such as the position of the target organ, patient’s
obesity and necessary extension of the incision (Pafko et al., 2006, p. 24). Laparoscopy
represents an optical surgical technique which is performed with the help of laparoscopic
ports introduced into the abdominal cavity through several millimetres long incisions. Any
procedure can be performed laparoscopically on the intestine – from the ileocecal resection to
low rectal resection, including total colectomy (Hoch et al., 2011, p. 239). Both surgical
procedures include pre-surgical, peri-surgical and post-surgical care, which entail financial
costs related to the health care provided. The actual post-surgical course and recovery time
represent important indicators of patient’s quality of life.
In the recent years, we have observed an increasing preference of laparoscopic procedures in
the treatment of the benign and malignant colorectal diseases. Our aim was to compare the
effectiveness of nursing care in patients after colorectal surgery performed by both surgical
procedures – laparotomy and laparoscopy. We were assuming that the choice of the surgical
procedure significantly influences the overall post-surgical course and the extent of nursing
care.
The aim of our research was to compare the nature and extent of nursing interventions in
patients undergoing colorectal surgery performed by laparotomic and laparoscopic
procedures. In order to meet the given objective, we were observing differences in surgical
procedures, focusing on the post-surgical care in the following areas: monitoring of vital signs
(blood pressure and body temperature), post-surgical pain attenuation, parenteral and enteral
nutrition, excretion, surgical wound, hygienic care and length of hospitalization. The above
stated nursing interventions are commonly provided in both types of surgical procedures.
METHODS
Our research has been carried out in 2012 in a hospital located in eastern Slovakia. In order to
meet the given objectives, we applied quantitative research method of document content
analysis. 60 medical records were monitored during the first seven days of post-surgical care.
Researched medical records were divided into two groups: patients after laparoscopic
36
surgeries and patients after laparotomic surgeries. We created a database of collected data and
performed interventions through numeric codes. The evaluation of nursing care was
conducted based on 20 items that represented ordinal variables of n-degree range, allowing
the score to be determined from the minimum frequency of nursing interventions provided
(nmin = 1, or 0 when intervention was not performed) to the maximum frequency (nmax =
highest number) of the observed intervention in case of both surgical procedures. The results
were processed in SPSS 18.0 (Mann-Whitney U test).
RESULTS
The average age of patients included in both studied groups was 55 years ±SD 9.61.
Respondents’ gender represented another observed variable. The results of the analysis point
out to the fact that rectal resection by laparotomic procedure was underwent by 23 male and 7
female patients. The laparoscopic procedure was carried out in 16 males and 14 females.
We observed the frequency of selected 19 nursing interventions in both studied groups patients after laparoscopic surgeries and patients after laparotomic surgeries. Subsequently,
we examined a statistically significant relation between the two studied groups by means of
Mann-Whitney U test. The results of the research are listed in the below Table 1.
Type of surgical procedure used for colorectal surgery has also an impact on overall body
image. Laparotomic procedure requires a greater extent of skin integrity disruption, while
laparoscopic procedure is less harmful from this perspective. Patients from the researched
group who underwent laparotomy had a surgical wound of approximately 15-20 cm. As for
the patients that underwent laparoscopic procedure, 24 respondents had 3 surgical wounds of
approximately 2.5 cm and 6 respondents had one surgical wound of 4 cm. Regarding the
wound bandaging, we found out that after laparotomic surgical procedure, 10.8 bandages
were applied compared with laparoscopic procedure where we recorded an average of 3.86
bandages during hospitalization.
In many cases, patients after colorectal surgery require continuous post-surgical monitoring in
intensive care units. Length of patients’ hospitalization after both surgical procedures varied.
We can conclude that health care provided by intensive care units for the period of 2 days was
necessary for all the patients after laparoscopic procedure. In some cases, respondents that
underwent laparotomic procedure required a longer monitoring. However, 8 of these patients
were hospitalized in the intensive care units for one day only. When evaluating the overall
37
length of hospitalization of analysed group of respondents, we conclude that 23 patients
operated by laparotomic procedure were hospitalized for more than 10 days while remaining
7 patients spent 9 days in the hospital. In case of laparoscopic procedure, the overall length of
hospitalization of more than 10 days was necessary only for 4 patients, 9 days were needed
for 5 patients and 17 patients were hospitalized during 7-8 days only. The results of the
analysis clearly point out to the fact that from the perspective of the overall length of
hospitalization, laparoscopic intervention proves to be a more convenient surgical method.
Table 1: Comparison of nursing interventions after laparotomic and laparoscopic surgical
procedures
Nursing Interventions
Frequency of Performed
Surgeries
laparotomy / laparoscopy
Monitoring of vital signs
monitoring of vital signs - BP
laparotomy ↑
monitoring of vital signs - BT
laparotomy ↑
Frequency of oxygen treatment
laparotomy ↑
Post-surgical pain attenuation
opioid analgesic therapy
=
epidural analgesic therapy
laparoscopy ↑
analgesic therapy applied i.m. and i.v.
laparotomy ↑
Parenteral and enteral nutrition
parenteral nutrition
laparotomy ↑
central venous catheter insertion
laparotomy ↑
peripheral venous catheter insertion
=
administration of blood transfusion
laparotomy ↑
enteral nutrition
=
nasogastric tube insertion
laparotomy ↑
Excretion
clysma
=
laxatives
laparotomy ↑
permanent indwelling urinary catheter insertion
laparotomy ↑
Surgical wound
intensity of bandaging
laparotomy ↑
Redon drain insertion
laparotomy ↑
gravity drain insertion
=
Hygienic care
hygiene – full dependence
laparotomy ↑
hygiene – partial dependence
laparotomy ↑
↑ higher frequency of performed interventions
n.s. nonsignificant
= approx. the same amount of interventions
p statistical significance α= 0.05*
p statistical significance α= 0.01**
p - value
0.001**
0.003**
0.001**
0.970
0.024*
0.002**
0.001**
0.012*
0.814 n.s.
0.003**
0.227 n.s.
0.001**
0.317 n.s.
0.012*
0.023*
0.001**
0.040*
0.080 n.s.
0.001**
0.001**
DISCUSSION
The aim of our research was to focus on benefits of two different colorectal surgical
procedures – laparoscopic and laparotomic. Drahoňovský (2000, p. 54) mentions that it is not
appropriate to place these two methods in the opposition. He states that the laparoscopic
method is advantageous for the patient because it has minimal incision, allows working with
38
small tools, avoids medical masks and reduces the incidence of bruised tissue. As
a consequence, digestive tract is restored faster, surgical wound is less painful and the risk of
early complications is reduced. On the other hand, laparotomy represents a well-established
standard of finishing the surgery when complications occur. In our researched group of
patients, we came up with similar results. We focused on specific nursing interventions which
represent a standard of patient post-surgical care and which are realized in case of both
surgical procedures.
In total, we observed 7 areas of medical and nursing care by means of 20 interventions. In 14
cases, the higher number of nursing procedures was confirmed within the post-surgical care in
patients after laparotomy. Benefits of laparoscopic surgical procedure are also supported by
findings of the study Norwood et al. (2011, p. 1303) which analysed number of hours of postsurgical nursing care provided in 97 patients (laparoscopy n=53; laparotomy n=44). The
average amount of hours of nursing interventions performed per patient after laparotomy was
80 while after laparoscopy it was 58.5 hours.
Pain is one of the most significant and present nursing issues which reduces patients’ quality
of life. It represents one of the most common symptoms in patients in hospital environment,
involving complex physiological and psychological reactions (Tebeľáková, 2011, p. 148).
In our research, we focused on the methods of pain attenuation after respective surgical
procedures. Babiš (2010, p. 109) compared laparotomic resection with the resection of
colorectal cancer by laparoscopic procedure. Findings of his prospective analysis suggest less
frequent use of opioids in the immediate post-surgical period in case of laparoscopy – 1.3 %,
compared with 35 % in case of laparotomy. Results of our analysis of the studied group of
patients coincide with his findings. Similarly, our discoveries coincide with the findings of the
authors Otteová, Plevová (2011, p. 224) who mention lower pain intensity on the VAS scale
in the immediate post-surgical period after laparoscopic cholecystectomy in comparison with
laparotomic procedure. Tebeľáková (2011, p. 150) states that pain intensity is the main factor
determining the overall impact of pain on the patient.
From the economic perspective, it is important to monitor the overall length of patients’
hospitalization. Our findings related to the overall length of hospitalization prove shorter
hospitalization in patients after laparoscopy and they are consistent with the findings of the
author Veldkamp (2011, p. 83) who indicates the average length of hospitalization in patients
after laparoscopy as 5.6 (±0.26) days while after laparotomy he mentions 6.4 (±0.23) days.
39
Overall, we can conclude that laparoscopical surgical procedure seems to be more beneficial
for our researched group of patients. Our findings are comparable with the prospective
analysis of the above-mentioned author Babiš (2010, p. 109) who points out to the benefits of
laparoscopic surgeries. Authors Vrzguľa et al. (2011, p.7-10) and Norwood et al. (2011, p.
1303-1307) equally draw attention to the advantages of post-surgical care after laparoscopic
procedure.
CONCLUSION
Nowadays, a choice between laparotomic and laparoscopic procedure in relation with the
quality of patient’s life during the period of post-surgical care is a frequently discussed topic.
In our research, we followed 19 surgical interventions which are performed within postsurgical care in patients after both surgical procedures. Observed interventions were focused
on the area of monitoring of vital signs, post-surgical pain attenuation, parenteral and enteral
nutrition, excretion, surgical wound and hygienic care. The length of hospitalization was
treated separately. From this standpoint, a lower number of performed nursing interventions
was confirmed in patients after laparoscopic procedure in the vast majority of cases. The
overall length of patients’ hospitalization also proves to be in favour of laparoscopy.
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(France)]:Keyhole in garden gate, 2011 [cit. 2014-13.09]. Dostupné z:
http://laparoscopicsurgeryforcoloniccancer.euProcess.pdf
VRZGUĹA A, MÚDRY M, KOVÁCSOVÁ A, SLÁVIK J. SILS cholecystektómia a inguinálna hernioplastika
jedným prístupom – kazuistika. Miniinvazívna chirurgia a endoskópia chirurgia súčasnosti [online]. [Banská
Bystrica (Slovakia)]: Marko BB spol.s.r.o., 2011, vol. 15, no 4, p. 7 - 10 [cit. 2014-13.09]. Dostupné z:
http://laparoskopia.info/pdf/CASO-4-2011 Process.pdf.
40
CONTACT AN AUTHOR
doc. PhDr. Lucia Dimunová, PhD.
Department of Nursing, Faculty of Medicine, Pavol Jozef Šafarik University, Kosice
Tr. SNP 1, 040 11 Košice, Slovak Republic, Europe
e-mail: [email protected]
41
THE β RATING SCALE TESTING RESULTS OF THE SELFSUFFICIENCY LEVELS IN PATIENTS WITH MULTIPLE SCLEROSIS
Frčová Beáta, Rapčíková Tatiana, Beňadik Juraj
Frčová, B., Rapčíková, T.: The Department of Nursing, Faculty of Health located in Banská
Bystrica, Slovak Medical University, Bratislava
Beňadik, J.: IT, Hospital Zvolen
ABSTRACT
Background: The aim of the Study was to analyze the results of Newly Formed β Scale Test
Phase 1 by the authors, which has been designed to assess the level of self-sufficiency in
patients with multiple sclerosis.
Methods: 122 patients with a clinical diagnosis of multiple sclerosis from the hospitals
located in the Czech Republic and the Slovak Republic were involved in the testing. To
determine the β Scale reliability, the Cronbach Alpha Coefficient was applied. The median,
arithmetic mean and mode were calculated within the scale individual items.
Results: Based on the statistical processing, the Cronbach Alpha Coefficient amounted to
0.83, which represents a high degree of the scale reliability, with the average scores as
follows: 14.03 for patients, 11 for median and 8 for modus.
Conclusions: The results were compared to the similar studies carried out in the Slovak
Republic and abroad, especially those by Bartos, et al. (2009) and the daily activities test
results in adolescents and adults by Maenner, et al. (2013). In this respect, we note that the
newly created scale could have been a suitable tool for assessing the self-sufficiency in
patients with multiple sclerosis, not only by nurses, but also by the patients in the neurological
nursing field.
Key Words: result, scale, level, self-sufficiency, multiple sclerosis.
INTRODUCTION
The Multiplex Sclerosis (hereinafter referred to as the „MS“), as a nosological entity, was first
described in 1860 and it ranks among the most common causes of disability from neurological
causes in 20 - 40 year old adults. The MS interferes with the lives of the affected persons, but
42
sometimes even a long duration may not limit the self-sufficiency of human and paralyze
his/her physical performance (Havrdová, 1998). However, in most cases, the affected persons
have been limited in self-sufficiency skills and coping with the common activities of daily
living. In the subjects, the sense of self-being has been violated, there is a reduction in the
conditions and activities necessary for full life, perceived and expressed by the individuals as
a reduction in quality of their lives (Havrdová, 1998, Janáková, 2002).
The basis for formulating the β self-sufficiency scale rating, as proposed by us, were as
follows: Kurtzky´s incompetence scale and the EDSS disability scale widespread; the
Clifton’s self-sufficiency scale; MS diagnostic criteria.
The aim of the β scale is to assess the self-sufficiency level in the patients with multiple
sclerosis. The scale is designed for nurses who care for patients with this challenging clinical
diagnosis and also as a self-assessment tool by patients. We expect the patients to be assessed
by themselves via the scale and the nurse will objectify the results during the patient’s visit to
the outpatient department or repeated hospitalizations.
METHODS
The self-sufficiency rating scale evaluation in the patients with MS was carried out in several
phases:
 Creation of a new scale based on the above mentioned scoring and evaluative scales of
patients with MS.
 Testing the scale by the nurses taking care of patients with MS in hospital and outpatient
departments.
 The self-sufficiency assessment by the patients, while the patients handed the evaluation
over to a nurse during the examination.
The β scale has been the evaluative scale type, formulated so as to be as simple as possible to
fill in. It includes 20 items - needs, which undergo evaluation with 0 - 4 score using the scale.
The items include the selected basic needs, such as movement, intake of food and fluids,
emptying, food preparation, dressing, undressing, fine motor skills, grooming and body
hygiene. Items Group 2 includes active exercise, time and space orientation, visual and
auditory perception, sleep and rest. Field 3 has been focused on communication, learning,
leisure activities, work, culture and ROSKA Club’s activities. The evaluative scale is as
follows: 0 - 15 score - independent; 16 - 30 score - partially dependent on third person’s
43
assistance; 31 - 45 score - significantly dependent on third person’s assistance; 46 - 60 score totally dependent on third person’s assistance.
For the assessment purposes of this newly created scale reliability, we used the Cronbach´s
alpha coefficient. We then calculated the permanent score in the patients with multiple
sclerosis from the values found, and set both the median and mode as an average scale. We
expressed the highest and lowest self-sufficiency rates as a percentage.
For the β scale testing purposes, we requested co-operation of the organizations as follows: II.
Department of Neurology of SMU of Faculty Hospital F. D. Roosevelt in Banská Bystrica,
Department of Neurology of Thomayer Hospital in Prague, where the testing took place and
the results have been included in the analysis; I. Department of Neurology of Faculty of
Medicine, Komensky University in Bratislava and Department of Neurology of General
Hospital in Žiar nad Hronom. Testing was only successful in two of the sites addressed Department of Neurology of Thomayer Hospital in Prague and Department of Neurology of
General Hospital in Žiar nad Hronom.
RESULTS
122 patients with multiple sclerosis diagnosed were engaged in the testing. 110 patients came
from Thomayer Hospital, Prague; Centrum pre liečbu demyelizačných ochorení; and 12
patients came from General Hospital in Žiar nad Hronom. The group of 122 patients included
91 women, representing 74.60 %, and 31 men representing 25.40 %. The patients aged 41 to
50 years formed the largest group. The testing took place from December 15, 2011 to March
02, 2012 in Thomayer Hospital, Prague, and that in General Hospital, Žiar nad Hronom, took
place from December 1, 2012 to March 31, 2013. The results were recorded in the tables
followed by the statistical evaluation within the various aspects of self-sufficiency assessment
in the patients with MS.
The Cronbach's alpha coefficient value amounts to 0.83. Whereas those exceeding 0.70 or
0.80 prove adequate internal consistency of the scale created. The Cronbach's coefficient high
value also indicates that the aspects tested show sufficient correlation rate and that there has
been a sufficient number of subjects tested. The self-sufficiency average score amounts to
14.02 in patients. Comparing this figure to the evaluative scale range, the patients are ranked
in the independent patients’ category. The patients achieved the highest value under item 15
(0.36) - representing communication; and under item 18 (0.34) - leisure activities. The
44
patients achieved the lowest value under item 20 (2.84) - representing a visit to ROSKA Club;
and under item 16 (1.45) - work and employment. The nurses and patients rated the scale as
clear and easy to use for the purpose of assessing the self-sufficiency.
DISCUSSION
To assess the patient’s life quality, the valid and reliable standardized questionnaires are used
in medical practice. The assessment of self-sufficiency level of patients forms an important
indicator for efficient work of nurses. Vaňásková and Bednář (2013) provided a detailed
analysis of the life quality evaluation parameters through different specific tests in patients
with neurological diseases, including MS. They note that during the period of 10 years, the
patient's life quality significantly decreases since disease onset (Vaňásková 2013, p. 133-135).
It is mostly reflected in the field of employment, as confirmed in our study. Bartoš et al.
(2009) chose to use the DAD-CZ Self-sufficiency Questionnaire (Czech version) in
neurological patients. The questionnaire contains 17 normal activity items, 18 instrumental
activity items, and 5 items related to leisure and homeworks (Bartoš 2009, p. 320-323).
Generally, they evaluated it in a positive way, as it allowed the degree of coping with daily
activities to assess within 10 minutes. In turn, Dale at al. (2011) monitored the selfsufficiency level in geriatric patients to determine the threshold when the patient is capable of
performing the common activities of daily living by himself, and when he/she no longer needs
the assistance by professional agencies. To assess the self-sufficiency, they used the
evaluation questionnaire designated as ASA (AppraisalofSelf – careAgencyscale). The
questionnaire included 24 items divided into five categories. Minimum score to gain was 120
(Dale 2011, p. 113-122). The β scale contains 20 items, which, given the clinical diagnosis of
MS, takes into account the activities of daily living, but also the fine and gross motor skills
area affected with this type of disease. Maenner et al. (2013) described the Waisman
Activities of Daily Living (W-ADL) evaluative scale development and testing, which they
made subject to the test sample of 1 014 respondents in adolescence and adulthood age
suffering from developmental disorders. The Cronbach´s coefficient of the test W-ADL scale
amounted to 0.92 - 0.93, i. e. a high degree of the scale reliability (Maenner 2013, p. 8-17).
The Cronbach´s β scale coefficient amounted to 0.83.
CONCLUSION
The nursing care quality enhancement includes, but not limited to, the use of the objective
instrument to assess the patient's self-sufficiency. The self-sufficiency β evaluative scale in
45
patients with SM allows not only the nurses, but also the patients to assess self-sufficiency
level. Thus, the patient becomes a nurse’s active collaborator and an active participant
involved not only in the treatment process, but mainly in the process to maintain a reasonable
quality of life.
Table 1: ß – scale assessment of the self-care level in patients with Multiple Sclerosis
(Authors: doc. PhDr. Beáta Frčová, PhD., MPH and PhDr. Tatiana Rapčíková, PhD.)
Ref.
N0
1.
REQUIREMENTS
0 points
1 point
2 points
3 points
Gross motor skills movement
Independent
movement, no
problems
Independent
movement,
problems with
overcoming the
barriers and
obstacles
Movement with
the use of
assistive aids
Immobile
patient
(wheelchair, bed
rest)
2.
Intake of food and
fluids
Independently, no
assistance needed
Independently,
difficulty in
grasping
Needs help
(cutting, table mat
placing)
Assistance in
feeding by
another person
3.
Food preparation
Independently
Independently
with difficulties
(long and slow
preparation,
fatigue)
Separately, needs
to have the
kitchen-ware
height and
location adjusted
Failure to
prepare food by
himself
4.
Bladder emptying
Independently,
periodically, no
problems
Sometimes needs
help, occasional
involuntary
passage of urine
or stool
Frequent,
spontaneous urine
leaking with the
use of assistive
aids
Incontinence
5.
Emptying of the
colon
Independently,
periodically, no
problems
Occasional
problems, as for
constipation
Frequent
problems, as for
constipation
Incontinence
6.
Dressing,
undressing
Independently, no
assistance needed
Independently,
actions take
longer time
The assistance by
another person is
needed
7.
Fine motor skills
Trouble free, no
numbness
Numbness of
fingers and arms
Significant
paraesthesia,
considerable
effort in grasping
Full support of
the
neighbourhood
is necessary
Intention tremor
8.
Grooming,
aesthetics
Independently,
with an interest in
own appearance
Independently,
without an
interest in own
appearance
Occasional need
of assistance by
another person
Indispensable
assistance by
another person
9.
Bodily hygiene
Independently
Independently,
with the use of
safety aids
Independently
with partial
assistance
by another person
Indispensable
assistance by
another person
46
10.
Active exercise,
rehabilitation
Independently,
several times a
day
Independently,
once a day
Periodically,
he/she needs
assistance by
another person
Confused,
disoriented
Immobility
11.
Orientation in time
and space
Fully oriented
person
Occasional
disorientation,
especially in the
afternoon, he/she
needs help
12.
Visual perception
No restriction
Loss of visual
acuity, double
vision
Reduction of
visual field,
paresisoculomotor
nerves
Hearing loss,
the need for
assistive aids
Blind
13.
Hearing perception
No restriction
Impartial reduced
audibility
assessment, no
need for assistive
aids
14.
Rest and sleep
Sleeping without
interruption and
well
Wake up at night,
1 - 3-times
Wake up at night
more than 3-times
Insomnia
15.
Communication
Active, adequate,
fully preserved
non-verbal
expressions
Impaired
articulation, nonverbal expressions
somewhat limited
Significantly
more difficult,
poor non-verbal
expressions,
sadness prevails
Inability of
verbal and nonverbal
communication
16.
Work, employment:
No restriction
Employed, workload causes
problems
Part-time
employed
Total disability
17.
Learning, adoption
of new information
Active, no
restrictions
Adequate interest,
activity is limited
Decreased interest
in activities,
subjected to
moods and
surrounding’s
help
Inactivity
18.
Leisure activities
Leisure time spent
in an active way,
hobbies:
Active relaxation,
but assistance is
necessary
Leisure time spent
in an active way,
continuous
assistance
provided by
an assistant
Inactivity
19.
Visiting cultural
events
Periodically,
independently
Occasional
assistance
required
Very rarely and
limited
Inactivity due to
accompanying
symptoms
20.
Attends ROSKA
Club’s events and
activities
He/she helps
organizing
activities very
often
Only occasionally
Rarely and under
assistance
Attends club
activities
Number of points total
47
Deaf
REFERENCES
BARTOŠ A, MARTÍNEK P, BUČEK A, ŘÍPOVÁ D. The DAD - CZ Self-sufficiency Questionnaire – Czech
version for the daily activities evaluation in patients with Alzheimer's disease. Neurologie pro praxi. 2009,
Vol. 10, No 5, p. 320 – 323. ISSN 1213-1841.
DALE B, SODERHAMN U, SODERHAMN O. Self-care ability among home – dwelling older people in rural
areas in southern Norway. Scand J Caring Sci. 2012, Vol. 26, p. 113 – 122. ISSN 1471-6712.
HAVRDOVÁ, E. Roztroušená skleróza. Praha: Triton, 1998. 98 p. ISBN 80- 85875-79-9.
JANÁKOVÁ, M. Kvalita života a uspokojovanie potrieb ľudí s roztrúsenou sklerózou – sclerosis multiplex.
(Dissertation). Banská Bystrica: SZŠ, 2002. 71 p.
MAENNER J. M, SMITH E. L, HONG J, MAKUCH R, GREENBERG S. J, MAILICK R. M. Evaluation of an
activities of daily living scale for adolescents and adults with developmental disabilities. Disability and
Health Journal. 2013, Vol. 6, p. 8 – 17. ISSN 1936-6574.
VAŇÁSKOVÁ E, BEDNÁŘ M. Hodnocení parametrů kvality života u vybraných neurologických onemocnení.
Neurologie pro praxi. 2013, Volume 14, No 3, p. 133–135. ISSN 1213-1841.
CONTACT AN AUTHORS
doc. PhDr. Beáta Frčová, PhD., MPH
PhDr. Tatiana Rapčíková, PhD.
Faculty of health SZU, Sládkovičova 21, 974 05 Banská Bystrica
e-mail: [email protected]
e-mail: [email protected]
Ing. Juraj Beňadik
Hospital Zvolen, Kuzmányho nábrežie 28, 960 01 Zvolen
e-mail: [email protected]
48
IMPACT OF TREATMENT ADHERENCE THERAPY ON QUALITY
OF LIFE OF HIV - POSITIVE PATIENTS
Frei Jiří, Sedláček Dalibor
Frei J.:University of West Bohemia, Faculty of Health Care Studies , Department of Nursing
and Midwifery1 ;
Sedláček D: Charles University in Prague, Faculty of Medicine in Pilsen, Department of
Infectious Diseases University Hospital Pilsen2
ABSTRACT
Background: The investigation is aimed at the assessment of the impact of treatment
adherence therapy of the HIV positive patients on the quality of their lives. Overall, the main
predictors of the treatment adherence therapy not only in the field of antiretroviral therapy but
generally are: socio-demographic factors of a patient, treatment regimen, characteristics of the
disease, the relationship between a patient and a health professional or a medical facility and
entire clinical therapy setting.
Methods: A questionnaire was used as an exploratory research method of applied empirical
research. Resulting data of the questionnaire were compared with selected probands´
biometric markers. All the probands were HIV positive and subsequently underwent further
test and examination of urine samples to determine the levels administered drugs. HPLC
(high – performance liquid chromatography) was used for these purposes as fully certified
testing method. The levels of drugs: lamivudine, emtricitabine , stavudine and AZT were
monitored. All these substances create a part of antiretroviral combinations. The statistical
evaluation of the results was performed with methodology of serial correlation coefficients,
contingency charts and their analysis using the chi–square (X2) test - test of good compliance.
As well as the differences in frequency of responses in individual groups were compared and
statistical significance was evaluated, which was assessed at level α 1 ‰ (P = 0.001).
Results: Further the performed investigation found that selected social conditions of the HIV
positive patients have a clear impact on their subjective perception of the quality of life. This
is obvious, particularly, in the case in financial income and financial safety that the number of
69.77 % of respondents assessed these factors as average. Conversely, education, marital
status or occupation of respondents according to the subjective evaluation of them have no
effect in this area (39.54 % of respondents have secondary education without final leaving
49
exam and 30.54 % with leaving final exam). As well as the subjective perception of the
quality of life of non - adherent patients is lower than the subjective perception of the quality
of life of adherent patients.
Totally, 23 areas of human life were monitored, such as: health, self-sufficiency, sleep,
relationships, safety etc. Therefore, the treatment adherence therapy and nursing care closely
correspond with the quality of life of the HIV – positive patients. However, we cannot clearly
claim whether subjective health perception of the HIV – positive patients was better before
detection of their HIV status than during treatment. Before detection of the HIV positivity the
number of 6.98 % of respondents assessed their subjective health perception slightly below
the average, 44.19 % as average, 34.88 % slightly above the average, 9.3 % significantly
above the average and 4.65 % of repondents did not answer. After detection of the HIV
positivity a group of average evaluation increased up to 58.14 % and a group of slightly
below average increased up to 13.95 %. During direct subjective evaluation of their health
condition the number of 34.88 % respondents answered that they perceive worse health
condition in comparison with the period before detection of the HIV positivity. On the
contrary, the number of 6.98 % of respondents experienced improving of their health status.
Others perceive the identical health status before and after detection od their HIV positivity or
did not answer. The obtained data also pointed to the fact of decline in psychological wellbeing of the HIV – positive patients in comparison of periods before and after the detection of
their HIV status. Before detection of the HIV positivity totally 30.23 % of respondents
evaluated their mental status as average and the same number as slightly above average. The
number of 23.26 % of respondents evaluated their mental status significantly above average.
Conversely, in the period after the diagnosis, the number of evaluation "average" increased up
to 51.16 % of the respondents. Original numbers „slightly above average“ and „significantly
above average“ considerably decreased.
Counclusion: Based on an analysis of the results of the research investigation the specific
recommendations for practice with a focus on improving of adherence have been prepared.
Thanks to these recommendations we can achieve maximal efficiency and benefit in the
treatment of HIV/AIDS for the patient as well as for the whole health and social system of the
country.
Key Words: Adherence, AIDS, HIV, Quality of Life.
50
INTRODUCTION
Although the AIDS disease (Acquired Immunodeficiency Syndrome) has been known for
thirty years, it has still ranked among diseases which modern medicine with its high quality
therapeutic methods and procedures can not definitively cured yet. Therefore, the treatment is
focused on antiretroviral chemotherapy, prophylaxis, treatment of opportunistic infections
and the treatment and prevention of other complications associated with HIV/AIDS. In
addition, wide issues relating to the treatment of side effects of antiretroviral therapy
occurred.
In developed countries the HIV positive patients obtain high-quality treatment at a high level
mostly without any problems. If the treatment is to be really effective and increase or
maintain the quality of life within acceptable limits, it is necessary to focus on the treatment
adherence therapy. Currently, it is proved that the rate of adherence has a significant impact
on the overall success of treatment and the overall patient´s health. Similarly, the treatment
adherence therapy affects the entire prognosis of the disease as well as potential health, but
also bio-psycho-social problems and complications in a HIV positive patient´s life. The term
„adherence“ literally means adhesion, compliance, acceptability, etc. In connection with the
treatment, therapy and nursing care we consider a process comprising all above mentioned
activities performing in the way to minimize stress on a patient and not to restrict him/her in
common daily activities. At the same time, these activities must provide adequate quality of
life without worsening of a patient´s health condition. Adherence is also understood as the
extent which the patient's behavior corresponds with advices of the health professionals in.
Applied, empirical, quantitative – qualitative research was conducted in the years 2009 –
2013 at the University Hospital Pilsen, in the AIDS Centre of the Department of Infectious
Diseases. The research comprises the HIV positive male patients and female patients who are
monitored and treated in the AIDS Centre of the Department of Infectious Diseases,
University Hospital Pilsen. The research totally includes 43 patients (28 male patients, 15
female patients) with a mean age of 44 years. In the empirical part of the research all the
patients independently or with help filled in a questionnaires comprising 17 main items, a few
subitems and a few charts. Some selected items are based on the internationally recognized
standardized questionnaire RAND 36 – Item Health Survey (SF-36). Data obtained from the
survey are then confronted with the results of the examination of biological material collected
with the consent of all respondents of the survey. The biological material takes in urine of
51
patients who was examined by HPLC (high presure liquid chromatography) for the presence
of substances contained in the antiretroviral drugs administered to patients during their
treatment.
First of all, the attention was concentrated on the level of lamivudine. In adherent patients the
levels of lamivudine ranged from 35.2 to 1840.6 mg/l and the levels of emtricitabine 15.9 –
188 mg/l. The AZT level was 177 mg/l in a patient who was indicated in. In Stavudine any
level of a drug didn´t measure. All these mentioned substances make components of
antiretroviral combination therefore their determination is a suitable for control of the
treatment and verification of the level of adherence. The results of the analysis of data
obtained from the survey and sampling of biological material are statistically processed and
evaluated. The statistical evaluation of the results and confirmation of hypotheses were
verified with the methodology of serial correlation coefficients, contingency charts and
analysis using the chi-square (X2) test of good compliance. Simultaneously, standard
deviation, mean and range were determined for proper evaluation. These statistical methods
were chosen in particular with regard to the amount of data being analyzed and their
characteristics. The differences in frequency of responses in individual files were compared as
well. Statistical significance was assessed at level α 1 ‰ (P = 0.001). Hypotheses set out to
assess the impact of treatment adherence are:
Hypotesis
1H1
Selected social conditions of the HIV – positive patients have an impact on their
subjective perception of the quality of life.
2H1
The quality of life is in relation with the level of adherence of the HIV – positive
patients.
3H1
Subjective perception of the health status of the HIV – positive patients was better
before detection of their HIV positivity than in the course of treatment.
4H1
Psychological well-being of the HIV – positive patients before detection of their HIV
positivity was better than in the course of treatment.
RESULTS
Within the performed investigation it was found that selected social conditions of the HIV –
positive patients have an impact on their subjective perception of the quality of life. It means
52
that the hypothesis no. 1 was confirmed. Observing specific indicators it was be confirmed in
the financial position and creature comforts. Totally 69.77 % of respondents evaluate their
financial position as the average one. In contrast, education, the partnership - marital status
and employment, and some of the other observed factors do not affect the subjective
perception of the quality of life of the HIV – positive patients. (39.54 % of respondents:
secondary school without leaving exams, 30.23 % of respondents: secondary school with
leaving exams, 16.28 % of respondents: basic education, and 13.95 % of respondents:
university education).
Simultaneously, the subjective perception of the quality of life of the non-adherent patients is
lower than the subjective perception of the quality of life of the adherent patients. Therefore,
the hypothesis no. 2 was confirmed. We observed 23 areas of common life as health, selfsufficiancy, sleeping, relationships, safety etc. The adherent patients achieved higher level of
satisfaction and comfort in specified areas of life and resulting from this fact consequently
higher quality of life. Vice-versa the non-adherent patients didn´t achieve satisfaction in given
areas of common life significantly and quality of their lives was evaluated rather worse
compared with the adherent patients. This result confirms the fact that adherence therapy and
nursing care is closely related to the quality of life of the HIV positive people.
However, we cannot clearly claim that the subjective perception of health condition of HIV
positive patients was better before detection of the HIV positivity than in the course of
treatment. Using statistical method of serial correlation in the statistical insignificance of
interrelations identified in the analysis of given data was established. The estimated
probability was calculated only 15 % and therefore hypothesis no. 3 neither can be clearly
confirmed nor rejected. Before the detection of their HIV positivity 6.98 % of patients
qualified their health conditions slightly below the average, 44.19 % on average, 34.88%
slightly above average, 9.3 % significantly above average and 4.65 % of patients didn´t
answer.
After detection of HIV positivity a group of respondents with positive assessment increased
up to 58.14 % and a group of respondents with assesment „slightly below average“ increased
up to 13.95 %.
In direct subjective assessment of health condition totally 34.88 % of the respondents
answered that they experience worsening of their health condition in comparison with the
period before detection of their HIV positivity, and 6.98 % of the respondents feel
53
improvement. Others experience their health condition identically or didn´t answer. Although
according to some data, the situation could be resulted in the fact that the largest group of
patients consider their health condition on average and before the detection of their HIV
positivity it was assessed in an opposite way, the reality is different.
The health condition of a lot of patients, even before detection of HIV positivity was
worsened. In some cases regular monitoring in a medical facility and application of
preventive health measures improved health condition. It can be declared that most patients
subjectively assess their health status before and after diagnosis identically and only a small
part of patients experience the worsened health condition.
The obtained data also showed the fact of a deterioration of their mental health and
psychological well-being of the HIV positive patients compared before and after the detection
of their HIV positivity. The hypothesis no. 4 was confirmed. Before detection of the HIV
positivity the mental health was assessed by most of the respondents (30.23 %) as on average
and the same number rated their mental health as slightly above average. Totally 23.26 % of
respondents assessed their mental health above average. In contrast, after detection of
diagnosis, a number of evaluation "on average" increased up to 51.16 % of the respondents.
Numbers of respondents with evaluation „slightly above average“ and „significantly above
average“ notably decreased. We have to declare that the mental health of the HIV positive
patients should be continuously monitored, evaluated and supported not to cause negative
impact on other areas of life of HIV positive patients.
DISCUSSION
Comprehensive and partial results of the survey were compared with a number of foreign
studies. It can be said that the results are identical in the monitored parameters. In comparison
with foreign studies the care of the HIV positive patients in the Czech Republic is very good
and exceeds in a lot of many aspects the care abroad. A great benefit for patients in the Czech
Republic is focused on treatment availability and on coverage by health insurance companies.
It is clearly confirmed that the treatment adherence therapy significantly affects on the entire
success and it is essential to concentrate together with support of mental health of patients
explicitly to the treatment adherence therapy.
HIV/AIDS issues belong to wide area of both the nursing care and medical one. The
incidence of HIV/AIDS is still growing worldwide and therefore it is a global problem that
54
affects immediately each of us. In recent years all the people involved in the problem of
HIV/AIDS have realised that except creating of new therapeutic strategies, preventive
programmes etc. it is necessary to focus on their efficiency, quality and successful output. All
these atributs are associated with the adherence. One of the way how to monitor and assess
the adherence, treatment and nursing care is mesurement of drug concentration, respectively,
metabolites in blood or urine. This method was chosen as one of the parameters in the above described and realized investigation. The aim was to verify and evaluate the treatment
adherence therapy in relation to other areas of human life, such as its quality. The world
studies show that adherence of antiretroviral therapy, especially in some countries, it is not
ideal. In 2008, the rate of adherence, in an extensive study conducted by US scientists at the
Indiana University School of Medicine, was established in the HIV positive patients under 18
years of age in the range of 49 – 100 %. It is interesting that even in developed countries the
adherence is below 75 %. This is an alarming fact, because up to ¼ of the HIV positive
patients can experience in the course of their treatment and nursing care various not only
health but also mental and thus social problems and complications resulting from the
progressive failure of treatment. Other study focused on treatment adherence therapy of the
HIV – positive pregnant women is the study of the scientists from the USA – Stanford
University, which investigated whether the treatment adherence therapy of HIV/AIDS
pregnant women is related to the transmission of HIV to their baby. It has been clearly shown
that in adherent patients the transmission from HIV positive mother to child (vertically)
appears in fewer cases.
In our research investigation it was found that from the total number of 43 probands 93 % of
them in the course of treatment and nursing care were adherent. It was also demonstrated that
the selected social conditions of the HIV positive patients affect the subjective perception of
the quality of life of these patients. Financial situation and material safety belong to main
affecting factors. It was shown that better financial situation increases subjectively perceived
the quality of life of a HIV – positive patient. Conversely, education, partner or family
relationship and employment (in the event that a respondent is employed) did not affect the
subjective perception of the quality of life of the HIV – positive patients. Although,
respondents claim that the partnership has no effect on the perceived level of quality of life,
the research investigation has shown that the non – adherent patients are not satisfied with
partner relationships (with its level or degree of its accessibility) with comparison with the
adherent patients. The adherent patients achieve in higher number desired levels in a lot of
55
areas of human life and activities. Eg. better sleeping, family relations, etc. The study of
scientists from Houston Health Services Research and Development Center of Excellence
published in April 2014 also shows that HIV/AIDS adherence treatment and the quality of life
depends on self – monitoring of patients. If the self – monitoring is carried out regularly, it
means, that patients are invited regularly to the control examination and they are intervened
both through education and control of the administration of drugs, the adherence treatment
therapy is approximately 95 %. This figure is very close to our results achieved in the group
of 43 patients monitored in the AIDS Centre in the University Hospital Pilsen.
The quality of treatment and nursing care in this centre is at the world level and in some
respects exceeds the common average. At the same time the results of the study support and
correlate with our performed investigation. Another study, whose results confirm and support
the fact of high adherence of patients monitored and treated in AIDS Centre in the University
Hospital Pilsen, was published in the Journal of Adolescent Health in March 2012: Predictors
of Antiretroviral Medication Adherence Among a Diverse Cohort of Adolescents with HIV.
The results of the research investigation have shown that psychological well-being of the HIV
positive patients in many cases was better before detection of diagnosis than in the course of
treatment. This fact is demonstrated in international studies that are also aimed at the
interrelationship of the psyche and adherence. Nigerian scientists in the comparative study
have shown that both depression and other psychological problems of the HIV – positive
patients tend to be associated with their non – adherence, and this fact more affests higher
mortality of these patients. However, the risk of depression in the HIV patients has been
shown to be up to 5 times higher than in the remaining population. Psychological problems,
which HIV positive patients frequently experience, include fear, anxiety resulting from losing
friends or family members, but also decrease patient´s self-esteem or not quite perfect ability
to adapt to certain changes in patients´ life, associated with their HIV positivity. Almost 50 %
of respondents had experienced in the context with HIV/AIDS in their lives some crisis
period, which affected their psychological state. Eg. partner disagreements, or even break, or
job loss or death in the family. Monitoring and evaluation of the treatment adherence therapy
and nursing care have been shown as essential, both for health reasons, as well as economic
ones. The only way to ensure adequate effectiveness of the used means, as well as human
resources throughout the whole health system, not only within therapy with the HIV –
positive patients.
56
CONCLUSION
On the basis of analysis the results of the research investigation the specific recommendations
for practice with the impact on increasing of adherence can be determined. With these
recommendations we can achieve maximum effectiveness and benefit in the treatment of
HIV/AIDS for both the patient and for the whole health and social system of the country.
 In the course of the regular education to motivate patients to adhere preventive
therapeutic regime and thus contribute to improving of the treatment adherence
therapy and nursing care in the HIV positive patients.
 To monitor and evaluate continuously the degree and level of the treatment adherence
therapy and nursing care in the HIV – positive patients.
 Within medical and nursing interventions to promote mental state of the HIV positive
patients.
 Within multidisciplinary medical and nursing regime to cooperate with clinical
psychologists and other professionals from the fields of psychology, psychiatry and
sociology.
 Sufficiently and appropriately to notify the public and professionals of HIV/AIDS and
prevent the stigmatization of the HIV – positive people.
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PROCHÁZKA, I. 27/2010. HIV pozitivní umírají méně, ale rychleji. Zdravotnické noviny. 2010, roč. 59, č. 27,
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ROZSYPAL, H.; STAŇKOVÁ, M.; SEDLÁČEK, D. et al. 2010. Doporučený postup komplexní péče o dospělé
infikované HIV. Doporučený postup Společnosti infekčního lékařství České lékařské společnosti J. E.
Purkyně, Klin. mikrobiol. inf. lék. 2010, roč. 16, č. 5, s. 181-189. ISSN 1211-264X.
SEDLÁČEK, Dalibor., 2002. Komplexní přístup AIDS centra FN Plzeň k řešení problematiky infekce HIV/AIDS
v západočeském regionu. Plzeň: Plzeň. lék. sborn., Suppl. 77, 2002. s. 5-96.
UNIVERSITY OF CALIFORNIA SAN FRANCISCO. 2001. Adherence to HIV Antiretroviral Therapy [online].
California San Francisco: Univerzisty of California San Francisco. [cit. 2011-04-29]. Dostupné z:
http://hivinsite.ucsf.edu
Vreeman RC, Wiehe SE, Pearce EC, Nyandiko WM. A systematic review of pediatric adherence to
antiretroviral therapy in low- and middle-income countries. US National Library of
MedicineNational Institutes of Health. [databáze online]. PubMed. [cit. 2013-04-09]. doi:
10.1097/INF.0b013e31816dd325. Dostupné z: Chyba! Odkaz není platný.
CONTACT AN AUTHOR
PhDr. Jiří Frei, Ph.D.
Fakulta zdravotnických studií ZČU v Plzni
Tylova 59, 306 14 Plzeň, Česká republika
e-mail: [email protected]
58
THE QUALITY OF PATIENTS LIFE AFTER THE PERCUTANEOUS
CORONARY INTERVENTION
Haluzíková Jana, Zvolánková Eva
Haluzíková, J: Institute of Nursing, Faculty of Public Policies in Opava, Silesian University
in Opava
Zvolánková, E: University hospital Fakultní nemocnice Ostrava, Cardiovascular Centre
Kardiovaskulární centrum
ABSTRAKT
Background: This study was aimed at how the PCI affects life quality of patients suffering
from the chronic ischemic heart disease.
Methods: A quantitative research method using a questionnaire survey was used. The
standardized questionnaire WHOQOL BREF with 26 items was used to find out the life
quality. Respondents completed the questionnaire before the PCI, and upon discharging from
hospital they were given the questionnaire with an envelope which they completed after one
month following the PCI.
Respondents aged 45-65 with the ischemic heart disease, CCS I-II, were addressed.
Data for the life quality were processed according to the Brochure for Users of the Czech
Version of Life Quality Questionnaires by WHO. The basic descriptive statistics, paired nonparametric test was used for evaluation in the first and second measurements, the statistical
tests were evaluated on a significance level 5 %.
Results: We compared the results before the PCI and after the intervention. Some items
showed statistically significant differences between the first and the second measurements
(p<0.05). Although minor improvement occurred in these questions, in the end these positive
changes did not affect the results in any of the domains, thus became statistically
insignificant.
Conclusion: The results of the questionnaire survey showed that the respondents do not have
the decreased overall life quality compared to the population standard according to age
groups, which is mentioned in the Brochure for Users of the Czech Version of Life Quality
Questionnaires by WHO.
59
Key Words: quality of life, ischemic heart disease, percutaneous coronary intervention.
INTRODUCTION
Cardiovascular diseases rank among the most serious medical problems in industrially
developed countries all over the world. Nurses executing nursing interventions as parts of
preventive, diagnostic and treatment procedures play irreplaceable roles in comprehensive
care for patients suffering from cardiovascular diseases.
One of the most frequent cardiovascular diseases is the ischemic heart disease (IHD) which
can lead to decrease in life quality, incapacity of clients or even to their death. Treatment
possibilities are still being developed. One of them is the percutaneous coronary intervention
(PCI), during which correction to the narrowing (stenosis) or complete closing of the coronary
artery feeding the cardiac muscle is performed.
Life Quality in Nursing
“In nursing, life quality assessment is focused on human beings in their specific life situations
in relation to their health conditions. For further development of life quality in nursing,
formulation of real, generally acceptable definition of life quality based on patient’s
subjective perspective and perception of his/her own life is needed.” (Gurková, 2011, p. 25).
“Conceptualizing and definitions of terms linked to the life quality as well as indicators which
determine life quality by themselves, are not developed enough in our social and cultural
context of nursing, even despite the fact that the life quality is generally taken as the result of
medical and nursing care or an indicator of its effectiveness, which assumes definiteness
(factuality) and objective measurability of its reaching.” (Gurková, 2011, p. 26).
To improve life quality, it must be diagnosed as soon as possible, as it is a prerequisite for
success of nursing interventions focused on improvement in clients’ life quality.
Goal
To find out if life quality of a selected group of patients aged 45 to 65 has changed after the
invasive PCI.
The other intermediate goals focused on the following areas have been set out:
To find out whether life quality as to physical health has changed,
60
To find out whether life quality as to experience has changed,
To find out whether life quality as to social relationships has changed.
METHODS
The method of quantitative research was selected. The abbreviated version of the WHOQOLBREF questionnaire (QNR) was used. Social and demographic data (e.g. age, sex, other
chronic diseases, number of undergone PCIs, job, education, height, weight) were added to it.
We were also considered whether respondents smoke. The questionnaire was anonymous.
Consent with the research had been obtained prior to the research in the respective health
facility.
The WHOQOL-BREF QNR consists of 26 questions. It includes 2 separate items and 4
domains: physical health, mental health, social relationships and the environment. Closedended (scale) questions, when respondents expressed their attitude on the Likert scale, circling
the specific number from 1 to 5, were used.
The first two questions cover an independent topic and they are related to respondents’ life
quality and well-being. The other 24 questions are divided into 4 domains. These questions
were assessed and subsequently each domain was assessed.
Respondents were ranked to the set in the order in which they had undergone the intervention.
All the addressed respondents agreed with being included in the research. They filled the
questionnaire in before the PCI and they assessed their life quality at that time. Having been
discharged from hospital, they received another questionnaire and evaluated their life quality
after four weeks following the intervention. Then an analysis of the questionnaires before and
after PCI was performed.
Respondent Selection Criteria
The research set included men and women. It was a heterogeneous group of respondents who
had undergone the invasive PCI once or more times in the centre of invasive cardiology at the
University Hospital in Ostrava. The age of the clients ranged from 45 to 65. The basic
diagnosis was the chronic IHD CCS I-III.
RESULTS
The descriptive statistics (frequency charts with absolute and relative numbers, median,
arithmetic mean, standard deviation) was used for description of the set. For the assessment of
61
each question and domain in the first and second measurements, we used a paired
nonparametric test (Wilcoxon test). The statistical tests were assessed on the significance
level 5 %. The statistical processing was carried out with Stata v.10. Data collection and result
processing were performed with MS Excel.
Results of the Survey
The average age of respondents was 59.28, the youngest one being 48, whereas the oldest one
65. The age group of 65 was represented most (12, i.e. 17 % of respondents).
The sample included 20 women (28 %) and 51 men (72 %). In total 71 respondents. We
monitored the respondents for chronic diseases. The hypertension was the most frequent, 51
respondents (72 %). Diabetes mellitus occurred with 25 respondents (35 %). The least number
of respondents (10, i.e. 14 %) suffered from the chronic obstructive pulmonary disease.
We monitored how many times the respondents had undergone the intervention. Most
frequently the respondents had undergone it for the first time (52 respondents, i.e. 73 %), 14
respondents (20 %) had undergone it twice and 5 respondents (7 %) had undergone it multiple
times.
Based on their social position, the respondents were divided into 4 groups. The largest group
included employees (32 respondents, i.e. 45 %); further 31 respondents (44 %) were
pensioners and 8 respondents were people who had been given disability pension.
The average height of respondents was 173.63 cm and their weight 83.27 kg. Using the height
and weight, respondents’ average body mass index was calculated. The body mass index
(abbr. BMI) is a number used as an indicator of underweight, normal body weight,
overweight and obesity. Our sample of respondents showed the average of 27.62, i.e.
overweight.
Due to the fact that smoking is one of the most important risk factors accelerating the
atherosclerosis process, this question was also put in the questionnaire. The survey showed
that the majority of respondents (48, i.e. 68 %) are not smokers.
Processing of Individual WHOQOL-BREF Questions
How do you assess your life quality? (Q1)
Before PCI 59 respondents (82 %) answered this question that they consider their life quality
good. The next frequent answer was that their life quality was neither good, nor bad (7, i.e. 10
62
%). 6 respondents (8 %) think that their life quality was bad. None of them used the answer
very bad or very good.
After PCI most of the respondents (56, i.e. 79 %) answered again that they consider their life
quality good. The next frequent answer was neither good, nor bad (10 respondents, i.e. 14 %).
After the intervention, 5 respondents (7 %) think their life quality is bad. None of the
respondents used the answer very bad or very good (0 %).
Are you happy with your health? (Q2)
None of the respondents used the answer “very happy” before PCI. 11 respondents (16 %)
were not happy with their health. 28 respondents (39 %) were neither happy, nor unhappy.
The answer “happy with my health” was chosen by 32 of them (45 %). None of the
respondents chose the answer “very unhappy” (0 %).
Most respondents, 37 (52 %), answered after the intervention that they were happy with their
health. 23 respondents (32 %) answered they are neither happy, nor unhappy. 9 respondents
(13 %) were unhappy with their health. 2 respondents (3 %) were very unhappy. None of the
respondents chose the answer “very happy”.
The final data in the area of life quality from people suffering from the chronic IHD after PCI
do not show any improvement in life quality. In WHOQOL-BREF, tab. 1, the data from the
survey are compared. The first column shows results from the survey before PCI. In the
survey it was found out that respondents’ life quality did not deteriorate compared to the
normal population. The data from our respondents were compared with the data from the
normal population included in the Brochure for Users of Czech Versions of WHO QNRs. The
second column shows the results after four weeks following the PCI. In the last column, one
can see at which questions changes occurred during our research. Here we compare results
obtained before the intervention and 4 weeks after it. The questions where statistically
significant differences were found out between the first and the second measurements
(p<0.05) are in bold.
Assessment of Intermediate Goals
 The first intermediate goal was to find out whether the life quality as to physical health has
changed. The physical health domain includes 7 questions. The survey found out that
despite the fact that 3 questions, i.e. q3, q15 and q17, showed improvement, generally no
63
improvement occurred in the physical health domain. The results in the physical health
domain remained the same as they were before the intervention.
 The second intermediate goal was to find out whether PCI affected life quality as to
experience. This domain included 6 questions. In this domain, improvement in the
questions q19 and q26 occurred; however, the final survey showed that it did not affect the
domain as a whole.
 The third, i.e. the last intermediate goal was to find out how PCI affected the life quality as
to social relationships. One question (q20) was affected in this domain; however, the final
assessment of the domain was not influenced. No improvement in life quality in the area of
social relations was shown.
Table 1: Comparison of results from the 1st and 2nd QNR (nr. of respondents: 71)
Item
Before PCI
Median
Arith. mean
St. deviation
Min.
Max.
Median
Arith. mean
St. deviation
Min.
Max.
Paired non-parametric test, significance level 5 %
Quest. Nr. 1- Q1
4
3.77
0.57
2
4
4
3.72
0.59
2
4
0.2523
Quest. Nr. 2- Q2
3
3.28
0.72
2
4
4
3.34
0.81
1
4
0.2171
Quest. Nr. 3- q3
3
2.72
1
1
5
2
2.2
0.9
1
5
< 0.001
Quest. Nr. 4- q4
3
2.63
0.91
1
5
2
2.59
0.85
1
5
0.3796
Quest. Nr. 5- q5
4
4.11
0.92
2
5
4
4.1
0.91
2
5
0.981
Quest. Nr. 6- q6
4
4.13
0.89
1
5
4
4.07
0.83
2
5
0.2704
Quest. Nr. 7- q7
4
3.89
0.8
3
5
4
3.96
0.8
2
5
0.5747
Quest. Nr. 8- q8
4
3.72
0.91
1
5
4
3.65
0.88
1
5
0.1967
Quest. Nr. 9- q9
3
3.61
0.89
1
5
3
3.63
0.91
1
5
0.8899
Quest. Nr. 10- q10
4
3.9
0.76
2
5
4
3.83
0.81
2
5
0.3407
Quest. Nr. 11- q11
4
4.21
0.74
2
5
4
4.17
0.81
1
5
0.8337
Quest. Nr. 12- q12
3
3.31
1.01
1
5
3
3.23
1
1
5
0.5747
Quest. Nr. 13- q13
4
3.92
0.65
2
5
4
3.99
0.75
2
5
0.0371
Quest. Nr. 14- q14
4
3.7
0.85
2
5
4
3.77
0.78
1
5
0.5606
Quest. Nr. 15- q15
4
4.11
0.8
2
5
4
3.86
0.82
2
5
0.0024
Quest. Nr. 16- q16
4
3.77
1.02
2
5
4
3.75
0.81
2
5
0.541
Quest. Nr. 17- q17
4
3.97
0.72
2
5
4
3.83
0.74
2
5
0.0066
Quest. Nr. 18- q18
4
3.87
0.86
2
5
4
3.87
0.77
1
5
0.9999
Quest. Nr. 19- q19
4
3.9
0.7
2
5
4
3.75
0.69
2
5
0.0409
Quest. Nr. 20- q20
4
4.15
0.65
2
5
4
3.96
0.84
1
5
0.0016
After PCI
64
p-value
Quest. Nr. 21- q21
3
3.31
1.18
1
5
3
3.3
1.11
1
5
0.4719
Quest. Nr. 22- q22
4
4.1
0.8
2
5
4
3.99
0.77
2
5
0.124
Quest. Nr. 23- q23
4
4.08
0.81
2
5
4
4.04
0.73
2
5
0.6218
Quest. Nr. 24- q24
4
4.14
0.62
2
5
4
4.04
0.64
2
5
0.1912
Quest. Nr. 25- q25
4
3.77
0.87
1
5
4
3.8
0.77
2
5
0.7631
Quest. Nr. 26- q26
2
2.1
0.86
1
4
2
1.85
0.8
1
4
0.0008
DISCUSSION
Having compared final data obtained from respondents before PCI and data on life quality of
normal population from the Brochure for Users of Czech Versions of Life Quality QNRs, no
decrease in overall life quality occurs with our respondents compared to the normal
population.
Cassar and Baldacchino in their extensive work, which was divided into two parts, ranked
their respondents to subgroups of clients and they found significant differences, especially in
sex, education and support from friends and also a question about stress was included. All of
these were then compared with risk factors for the cardiovascular system (smoking, physical
exercises). This work considers feeling of safety and security positive, which is reflected in
the life quality most. It arises from the research that further investigation into relationships of
these interrelated quantities is needed. On the contrary, the work Quality of Life and Health
Status after Percutaneous Coronary Intervention in Stable Angina Patients: Results from the
Real-World Practice clearly shows improvement in the life quality of the clients who
underwent PCI within one year after the intervention(Cassar, Baldacchino, 2012).
Although no link between PCI and overall life quality improvement has been found,
informedness of both professionals and ordinary people on this treatment possibility should
not be underestimated. On the contrary, the information as possible prevention of acute
coronary syndromes should be better. Clients’ attention should be drawn to the results of the
research in each domain. Pain relieving and return to everyday activities are crucial. These
difficulties in the areas of life quality of the patients are described as first in literature. (Štejfa,
2007, p. 250) describes many factors inducing pain. It is necessary to point out that these
factors do not include only physical effort, but many common everyday activities, which may
deepen the feeling of fear and anxiety. The anginose pain is an intensive and very tricky
symptom as it often indicates an immediate life-threatening condition. (Špinar, 2003, p. 141)
in his book also points put another fact which must be considered. He emphasizes that the
pain is the last symptom through which the emerging of cardiac muscle ischemia manifests
65
itself. Within education, nurses focus on following the regimen which includes sufficient
physical activities, diet and smoking cessation. In the monitored set, 22 % of respondents still
smoke and most of them are overweight.
Although the survey results as a whole were not statistically significant, some improvements
in certain areas very important to clients with cardiovascular diseases for common life were
found out. Above all, these include the anginose pain, which is often perceived negatively and
is the cause of anxiety and fear. It is a factor inducing worries about client’s own life. It
makes the clients stop activities they used to do. They can be limited at work and in
developed disease stages even at very easy everyday tasks. The pain often occurs in very
tense psychical situations. Nurses within their competences focus on education with the aim
to keep the regimen, which includes diet with reduced amount of fat, regular physical activity
and smoking cessation. The willingness of clients to keep the regimen is considered crucial.
Issues of non-compliance should be dealt with in the future.
CONCLUSION
We have set out several goals. The first one was to investigate life quality of people suffering
from the stable angina pectoris before and after PCI. It arises from the survey that the overall
life quality was not significantly affected due to the intervention. The prerequisite is that life
quality of clients after PCI is determined by many other factors, e.g. accompanying chronic
disease, personal relationships, the living environment and other variables. Although
individual domains of life quality as per WHOQOL-BREF were not affected, in my opinion,
the survey results can be considered positive. Development of an educational document
containing data from this survey will be beneficial.
Nowadays nurses participate in education within their competences. Keeping regimen should
lead to improvement in life quality.
Finally it is necessary to point out that effort of health professionals to improve the abovementioned aspects will be beneficial only if the response of the clients is adequate. There are
more and more clients who, despite their disease, presence of risk factors and indisputable
impact on their life quality, do not pay enough attention to their health conditions and
sometimes they intentionally refuse to respect the proposed measures.
66
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http://www.ncbi.nlm.nih.gov/pubmed/23123651.
CASSAR, S., R BALDACCHINO, D. Quality of life after percutaneous coronary intervention: part 2. Br. J.
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http://www.ncbi.nlm.nih.gov/pubmed/23123890
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coronary intervention in stable angina patients: results from the real word practice. 2011 Jun 1;77(7):95460. doi: 10.1002/ccd.22746. Epub 2011 Mar 11. [cit. 2013-10-07]. Dostupné z:
http://www.ncbi.nlm.nih.gov/pubmed/20824752 [cit. 2013-10-07].
ŠTEJFA, M. Kardiologie. 3. přepracované vydání Praha: Grada Publishing, 2007. 776 s. ISBN 978-80-2471385-4.
ŠPINAR, J. Ischemická choroba srdeční. 1. vydání Praha: Grada Publishing, 2003. 364 s. ISBN 80247-0500-1.
CONTACT AN AUTHOR:
PhDr. Jana Haluzíková, PhD.
Silesian University in Opava
Faculty of Public Policies in Opava
Institute of Nursing
Hauerova 4, 746 01 Opava, Czech Republic, Europe
e-mail: [email protected]
67
QUALITY OF LIFE OF CLIENTS WITH CHRONIC WOUNDS OF THE
LOWER LIMBS
Janiczeková, Elena,Virgulová Jana, Melichová, Anna
Janiczeková, E.,Virgulová J: Faculty of Health in Banská Bystrica of the Slovak Medical
University in Bratislava
Melichová, A.: Secondary Health School Banská Bystrica
ABSTRACT
Background: To determine how clients with chronic wounds of the lower limbs treated at
home assess their quality of life. To identity differences in quality of life perception between
men and women, to check whether overweight or smoking affect clients' evaluation of their
quality of life.
Methods: Quantitative research method – WHOQOL-BREF questionnaire. Total number of
respondents with chronic wounds (n=70). Wound type: diabetic ulcers (n=40) and venous
ulcers (n=30). Average age 67.83 years, average BMI 27.31, smokers (n=30), non-smokers
(n=40), all receive treatment at home from home care nurses. The data was processed using
the Shapiro-Wilk test for normality, the F-test, the t-test with equal and unequal variance and
single sample hypothesis testing of the mean.
Results: We found that respondents in the sample reported a lower quality life than the
population norms. There was a statistical significant dependence in favour of men: domain 1
(p=0.025<0.05); domain 2 (p=0.028<0.05); domain 3 (p=0.022<0.05). Overweight does not
decrease quality of life and smoking decreases quality of life only in domain 4
(p=0.044<0.05).
The results of the research were compared with the WHOQOL-BREF population norms for
the 60-74 year old age group. The findings on the quality of life of Slovak clients with chronic
wounds on their lower limbs are below the WHOQOL-BREF norms for all studied domains
despite the fact that they are treated at home.
Conclusion: Chronic wounds have a significant impact on clients' quality of life. The use of
questionnaires as instruments for measuring quality of life makes it possible to identify the
impact of that illness has on the daily life of clients and to monitor changes in quality of life
after appropriate interventions are carried out.
68
Key Words: quality of life, chronic wounds, domains, research.
INTRODUCTION
According to the European Wound Management Association (EWMA), a chronic, or nonhealing, wound is a defect that lasts at least 6 weeks but not more than 53 weeks (Sokol,
2009). Chronic wounds do not follow the normal healing process and are characterised by
prolonged inflammation, inhibition of cell proliferation, incomplete remodelling of the
extracellular matrix and failure of epithelialisation (Čambal, 2012, p. 127).
According to Stryja (2010, p.180) if the wound does not heal in the ideal treatment, we
assume that the wound was interference with the normal reparative process. The most often
occuring non-healing wounds according to the specific nosological entities includes: etiology
of venous leg ulcers, arterial ulcers, pressure ulcers, exulcerated malignancy, neuropathic skin
ulcers - diabetic defects, surgical wounds healing by secondary intentions, skin ulcers in the
location of lymphedema and burns. From this classification can be derived the main causes of
non-healing wounds and on that basis can be after: determining, planing and implementing
interventions strategies with an effect of healing wounds.
The typical features of chronic wounds such as oozing, smell, pain and infectivity for the
vicinity are factors that strongly reduce quality of life and are a significant cause of morbidity
and mortality for a large part of the population (Čambal, 2012). According to UN statistics up
to 1 % of the European population, i.e. 6-8 million patients suffer secondary skin injuries
caused by treatment, and 4–5 % of patients with chronic wounds are people over 80 years of
age. Diabetic foot syndrome affects 5 % of people with diabetes in the Slovak Republic and
14–24 % of patients with diabetic foot require amputation (Kmecová, 2010, p. 496). 1 % of
the population of the Slovak Republic suffer from leg ulcers (Stryja, 2011, p. 148; Mazuch,
2013, p. 27). In the case of 5–20 % of patients who undergo operation there may be healing of
the operation wounds may be impaired and after 2–5 % of operations more serious infections
can occur. At the same time, there are many patients who cannot have an operation because of
a chronic wound (Flanagan, 2013).
At present, chronic wounds are among the largest problems in care, which worsen patients'
quality of life, limit their movement and restrict opportunities for work and social contacts
(Miertová, 2012, p. 113)
69
Heavily secreting wounds are economically and therapeutically demanding and their
treatment in the home environment is a challenge for all health care providers to understand
and improve the quality of life of clients in the home environment (Urgelová, 2013). Quality
is a crucial and multidimensional term for the assessment of the level of health care whose
level depends on a wide range of social, cultural and economic factors (Rapčíková, 2013,
p. 55). There are many definitions of quality of life but all seek to define elementary
satisfaction with life. Patient satisfaction is the most important factor determining the
evaluation of the quality of health care. Patients also assess health care according to how and
to what extent their needs are satisfied (Rapčíková, 2013, p. 59). Gurková (2011) interprets
quality of life as a description of positive and negative aspects of life determining whether or
not our life is of good quality and compares it with the desired expected level of existence or
the lives of other people. As the numbers of older people in the world have increased, the
analysis of quality of life has moved out of health care establishments and into people's daily
lives (Kováč, 2003).
The fact that researchers around the world have shown clear interest in the problem of quality
of life and the fact that its measurement has become an important part of the evaluation of
health care outcomes or the effectiveness of treatment from the patient's perspective is
reflected in a large number of analyses and recommendations for improving quality of life in
the global databases ProQuest Central, EBSCO, Scopus, Knovel etc. (Babinčák, 2013, p. 358)
A wide range of instruments for measuring quality of life are available for use in practice
including generic questionnaires, which are the same for any set of respondents regardless of
whether they are ill or healthy and not taking account of sex and age (ADL, SF36, NHP,
WHOQOL) and specific questionnaires designed for patients with certain types of illness
(QLQ-C30,FACT-G,RSCL) (Šupínová, 2013, p.4).
The main aim of our research is to determine how clients treated in the home by nurses from
the Home Nursing Care Agency (HNCA) who have chronic wounds of the lower limbs assess
their quality of life.
Research questions:
1 Does overweight affect the quality of life of clients with chronic wounds of the lower
limbs?
2 Does smoking affect the quality of life of clients with chronic wounds of the lower
limbs?
70
3 Is there a significant difference between men's and women's perception of quality of
life with chronic wounds of the lower limbs?
METHOD
Empirical data was obtained using a quantitative research method – the WHOQOL-BREF
questionnaire, which is widely used in other countries. We used the short version of it, which
contains 26 questions, is not overtaxing for respondents and comes with a population norm
for the relevant age group, 60-74 year olds (Dragomirecká, 2006, p. 43) The questionnaire
addresses 4 quality of life domains: domain 1 - physical health (pain and discomfort,
dependency on medical care, energy and fatigue, mobility, sleep, activities of daily living,
work performance); domain 2 - psychological health (positive feelings, meaning of life,
ability to concentrate, body image, self-esteem, negative feelings); domain 3 - social
relationships (personal relationships, sexual activity, support from friends); domain 4 environment (physical safety and security, environment, financial situation, access to
information, leisure activities, neighbourhood, access to health care, transport) and two
separate items Q1 - overall quality of life and Q2 - satisfaction with health. Data was
collected between January and May 2014. Data was collected in the Banská Bystrica Region
of the Slovak Republic, Home Nursing Care Agency (HNCA). The WHOQOL-BREF
questionnaire was evaluated using the procedure set by its authors. The results were analysed
further using the Shapiro-Wilk test for normality, the F-test, the t-test with equal and unequal
variance and single sample hypothesis testing of the mean (the variance of the population is
known).
RESULTS
Criterion for inclusion in the sample: age 60–74 years, chronic wound of the lower limbs,
client is in the home environment and treated by HNCA nurses. The sample was made up of
70 respondents of whom 41 were men and 29 were women. The average age was 66.20 years
for the men and 70.12 years for the women; the overall average age was 67.83 years. The
most common types of chronic wound in the sample were diabetic ulcers in the case of 40
respondents and varicose ulcers in the case of 30 respondents. The sample included 30
smokers and 40 non-smokers. The average height of the respondents was 169.63 cm, the
average weight 78.87 kg and the average BMI 27.31. Given that the average BMI was 27.31,
the sample was divided into a group of respondents with BMI ˂ 27.31 = 31 respondents and
BMI ˃ 27.31 = 39 respondents.
71
Table 1 shows the findings and a comparison of the values measured for the sample and the
overall population aged 60-74 years. The scores for each domain were calculated individually
using the procedure set by the questionnaire's authors.
Table 1: Quality of life of clients of the HNCA (comparison of values measured for the
population according to WHOQOL-BREF and the sample of respondents aged 60–74 years)
Population/
number average
STD
minimum
maximum
s
min
min
max
max
sample
domain 1
217
70
14.59
9.72
2.63
3.29 6.86 4.00 18.86 17.14
domain 2
217
70
14.36
11.97
2.11
3.38 7.33 4.00 18.67 18.67
domain 3
217
70
14.21
13.12
2.30
2.87 5.33 5.33 20.00 20.00
domain 4
217
70
13.09
12.43
2.05
2.58 8.00 5.00 19.00 17.50
Q1
217
70
3.83
2.9
0.69
0.95 2.00 1.00
5.00
5.00
Q2
217
70
3.33
2.4
0.87
0.91 1.00 1.00
5.00
4.00
Notes: x̅ − arithmetic mean, sample size, ∂ - standard deviation, - basic set of results for average population
values (Dragomirecká, 2006, p. 43).
The quality of life results for Slovak clients with chronic wounds of the lower limbs treated in
a home environment by HNCA nurses are lower in all the domains studied than the average
results given in the WHOQOL-BREF user manual for the 60-74 year age group (Table 1).
Table 2: Test for dependence in the perception of quality of life of clients with overweight
and normal weight.
 =0.05
BMI
domain 1
domain 2
domain 3
domain 4
Q1
Q2
̅
𝒙
<27.31
8.96
11.51
13.16
12.44
2.87
2.26
>27.31
10.33
12.34
13.09
12.42
2.92
2.51
s
<27.31
3.14
3.43
2.48
2.57
0.99
0.84
>27.31
3.32
3.34
3.18
2.61
0.93
0.85
test statistic
t
1.757
-1.028
-0.097
-0.020
-0.226
-1.170
critical region
W
t (−∞; −1.996⟩
t (−∞; −1.996⟩
t (−∞; −1.996⟩
t (−∞; −1.996⟩
t (−∞; −1.996⟩
t (−∞; −1.996⟩
∪ ⟨1.996; ∞)
∪ ⟨1.996; ∞)
∪ ⟨1.996; ∞)
∪ ⟨1.996; ∞)
∪ ⟨1.996; ∞)
∪ ⟨1.996; ∞)
significance
p
0.833
0.308
0.923
0.984
0.822
0.246
The test for dependence in the perception of quality of life by clients with overweight and
normal weight found that there was no significance between the assessment of quality of life
of clients with overweight and clients with normal weight (Table 2).
Table 3: Test for dependence in the perception of quality of life of smoking and non-smoking
clients
 = 0.05
smoker
domain 1
domain 2
domain 3
domain 4
Q1
Q2
̅
𝒙
yes
10.11
11.84
12.98
11.67
2.90
2.33
no
9.43
12.07
13.23
13.00
2.90
2.45
s
yes
3.15
3.27
2.91
3.07
0.89
0.84
no
3.40
3.50
2.87
1.99
1.01
0.96
ttest statistic
t
-0.861
0.270
-0.367
-2.073
0.000
0.530
critical region
W
t (−∞; −1.996⟩ ∪ ⟨1.996; ∞)
t (−∞; −1.996⟩ ∪ ⟨1.996; ∞)
t (−∞; −1.996⟩ ∪ ⟨1.996; ∞)
t (−∞; −𝟐. 𝟎𝟏𝟐⟩ ∪ ⟨𝟐. 𝟎𝟏𝟐; ∞)
t (−∞; −1.996⟩ ∪ ⟨1.996; ∞)
t (−∞; −1.996⟩ ∪ ⟨1.996; ∞)
significance
p
0.392
0.788
0.715
0.044
1.000
0.598
We also checked for dependence between the quality of life assessments of smoking and nonsmoking clients. We found that there is a statistically significant difference between smokers
72
and non-smokers only in domain 4 - environment (p=0.044<0.05). In domain 1 - physical
health (p=0.392>0.05), domain 2 - psychological health (p=0.788>0.05) and domain 3 - social
relationships (p=0.715>0.05) we did not find any statistically significant difference (Table 3).
Tests identified a dependence between men's and women's perception of quality of life in
domain 1 - physical health (p=0.025<0.05), domain 2 - psychological health (p=0.028<0.05)
and domain 3 – social relationships
Table 4: The test of dependence in clients' perception of quality of life between sexes
 =0.05
sex
domain 1
domain 2
domain 3
domain 4
Q1
Q2
̅
𝒙
men
10.37
12.62
12.78
12.46
2.93
2.51
women
8.81
11.06
13.61
12.38
2.86
2.24
s
men
3.35
2.98
3.22
2.67
0.93
0.98
women
3.03
3.75
2.24
2.49
0.99
0.79
test
statistic
t
1.997
-1.939
-1.270
0.133
-0.279
-1.235
critical region
significance
W
t ⟨𝟏. 𝟔𝟔𝟖; ∞)
t (−∞; −𝟏. 𝟔𝟔𝟖⟩
t (−∞; −𝟏. 𝟔𝟔𝟕⟩ ∪ ⟨𝟏. 𝟔𝟔𝟕; ∞)
t (−∞; −2.011⟩ ∪ ⟨2.011; ∞)
t (−∞; −1.996⟩ ∪ ⟨1.996; ∞)
t (−∞; −1.996⟩ ∪ ⟨1.996; ∞)
p
0.025
0.028
0.022
0.894
0.781
0.221
(p=0.022<0.05) found a statistically significant difference in the perception of quality of life
to the disadvantage of women. In domain 4 no statistically significant difference was found
between men's and women's perception of quality of life (p=0.894>0.05). We also found no
statistically significant difference in the sexes' perceptions of quality of life for question Q1 quality of life (p=0.781>0.05) and Q2 - satisfaction with health (p=0.221>0.05).
DISCUSSION
The research sample was made up of respondents aged 60–74 years with chronic wounds of
the lower limbs. Čambal (2012, p. 127) highlights the fact that 85 % of all people affected by
chronic wounds are over 65 years of age. Miertová and Ďurkechová (2012, p. 117) state that
patients aged between 70 and 79 years have the biggest problem with varicose ulcers. They
are much more likely to perceive a worsening of the condition of a wound (p=0.030) that
significantly impacts their quality of life. In the sample of respondents for this research, the
overall quality of life, satisfaction with health and quality of life in individual domains was
found to be lower than the population norm for the given age category according to
Dragomirecká (2006, p. 46) (Table 1) With regard to the question of whether overweight
affects quality of life, no statistically significant dependence was found in the studied group
of respondents, who responded the same satisfaction with quality of life at BMI < 27.31
and BMI > 27.31. The hypothesis was based on the study by Guo and Di Pietra (2010) who
found that obese and overweight individuals more frequently suffer early complications,
73
infections, dehiscence, pressure sores and leg ulcers. Furthermore it is harder for obese and
overweight patients to move about, which increases the risk of injury because movement
causes tissue stress, which reduces microperfusion and the ability of oxygen to reach the
wound. Obesity and overweight also have a negative effect on incision wounds after an
operation, increasing tension at the edges of the wound, which can facilitate reopening. These
are factors that reduce wound healing and could be reflected in quality of life. The average
BMI for older people is higher: in the range 25-27 (Németh, 2009). The average BMI for the
sample, 27.31, is broadly within the norm and is therefore not the severe overweight that
would cause the complications for wound healing described by Guo and Di Pietra, which
would impair clients' quality of life. As regards the question of whether smoking affects the
quality of life of clients with chronic wounds of the lower limbs, our research found there was
a statistically significant difference between smokers and non-smokers only in domain 4 environment, where smokers (n=30) (p=0.0044<p=0.05) reported a lower quality of life
(Table 3). This hypothesis was also based on the study by Guo and Di Pietra (2010), which
investigated the influence and effects of cigarette on the cells of healing wounds. They found
that the wounds of smokers closed very slowly or remained open and could over time become
a nidus for local and overall infections. It would appear that smokers are not concerned that
cigarette smoke has a negative effect on the healing process since in domains 1 to 3 it is not
reported to impair quality of life. On the other hand in domain 4, even though the respondents
are in their own home, they feel isolated and misunderstood with their habit. Smoking is also
expensive and has a strong impact on the finances, and thereby on the quality of life, of
certain respondents. With regard to the question of differences in quality of life between the
sexes, significant differences were found in domain 1 - physical health, domain 2 psychological health and domain 3 - social relationships, where women reported a worse
quality of life than men. Dragomirecká (2006, p. 14) reports differences in the perceived
quality of life in favour of men in domain 1 - physical health, domain 2 - psychological health
and domain 3 - environment. We found differences in perceptions of quality of life to the
disadvantage of women in domain 3 – social relationships to the disadvantage of women,
where women respondents reported decreased quality of life. Farský a Solárová (2010, p. 36)
studied the quality of life of older people in community establishments and found that men
were somewhat more satisfied with their quality of life and health than women (score 3.0),
women (score 2.6). In studying differences in perceptions of pain, Miertová and Ďurkechová
(2012, p. 117) state that one of the most important phenomena regarding differences in the
74
assessment of quality of life between the sexes is that men bear pain better than women.
Using a numerical pain scale, men reported pain with a value of 3 (mild pain), while women
gave number 5 (moderate pain). These differences in the value for pain could also relate to
findings that women perceive pain more sensitively and intensively than men because they
have a lower sensitivity threshold (Miertová, 2012). In a study of the health and quality of life
of older people Junger et al. (2006, p. 80) found differences in coping with life situations in
favour of men. Whereas 25.71 % of men reported coping easily and without feeling stress, the
corresponding percentage of women was only 5.66 %. The same study finds greater selfsufficiency in movement for men than for women, a factor that significantly affects
individuals' quality of life. We did not find any other relevant studies concerning the quality
of life of clients with chronic wounds of the lower limbs treated by HNCA nurses in the home
environment.
CONCLUSION
The results of our research indicate that chronic wounds have a strong impact on the quality
of life of Slovak clients in the home. The results of our survey indicate that clients with
chronic wounds of the lower limbs have a reduced quality of life compared to the average
population values, despite the fact that they are being treated in their home environment by
professional HNCA nurses. We found that mild overweight does not have an effect on clients'
quality of life in any of the four domains, that smoking affects quality of life only in domain 4
- environment and that there is a significant difference between men's and women's perception
of quality of life in domains 1, 2, and 3, where women give a worse evaluation of quality of
life than men. Evaluation of the quality of life of patients with chronic wounds in the home is
important for the provision of quality healthcare by HNCA nurses. The objective of care for
clients in the home environment is to create conditions for comprehensive, multidisciplinary
care that takes into consideration the client's age, sex, overall malnutrition, the type of chronic
wound and the environment in which the client is situated (Duminová, 2013). The use of
questionnaires as instruments for measuring quality of life makes it possible to identify the
impact of that illness has on the daily life of clients and to monitor changes in clients' quality
of life after appropriate interventions are carried out. Questionnaires for the assessment of
quality of life can be incorporated into routine examinations of the client by a HNCA nurse
and thereby help to improve communication between the client, the HNCA nurse and family
members.
75
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CONTACT AN AUTHORS
PhDr. Elena Janiczeková
Faculty of Health in Banská Bystrica of the Slovak Medical University in Bratislava
Sládkovičova 21, Banská Bystrica 974 05, Slovak Republic, Europe
e-mail: [email protected]
77
AWARENESS OF GRAVIDITY, CHILDBIRTH AND
CONTRACEPTION AMONG GIRLS AT THE AGE OF 16 – 18
Kelčíková Simona, Mazúchová Lucia, Kamenská Gabriela
Department of Midwifery, Jessenius Faculty of Medicine, Comenius University
ABSTRACT
Background: Girls awareness of gravidity, childbirth and contraception is considered to be
important from the point of correct decision making in the area of sexual behaviour, in
preventing unwanted pregnancy and awareness of potential risks. The goal of the study was to
identify the awareness level of gravidity, childbirth and contraception among girls at the age
of 16-18.
Methods: The quantitative research method - explorative method of questionnaire. 98
questionnaires have been analysed and the categorized criterion was age and gender (girls 16
– 18 years old). The average age was 16,95 (±0,76). The questionnaire has included 3 areas –
gravidity, childbirth and contraception. We have reached a recoverability of 89 %. We have
used a descriptive statistic to process gathered data from a questionnaire (absolute and relative
frequency, SD, median and modus).
Results: Results of the research have identified the most common source of information:
concerning gravidity among the girls in this age category, it was internet (53 %), concerning
childbirth, the information mostly come from parents (53 %) and about the contraception, it
was internet (53 %). We have found out that self-evaluation of our respondents awareness
about this topic was average by 58 %, sufficient by 28 %, above-average by 6 % and
insufficient by 8 % of girls. Majority of respondents (73 %) has expressed interest in gaining
more information about the gravidity, childbirth and contraception. Statistical analysis by the
ANOVA test with the hierarchical design has not proved significant influence in the selfevaluation of students awareness in regards to the type of frequented school, to the behaviour
in the sexual area or concerning their religion.
Conclusion: The results refer to the fact the internet and information from the side of parents
are the most common information sources about this topic. These sources are however not
providing always sufficiently objective information. Knowledgeable medical personnel (such
as gynaecologists, midwives) should be the main providers of information in this area. (As 73
78
% respondents have expressed interest in other information, from the point of society, it is
important to increase the awareness of this area for this age group).
Key Words: gravidity, childbirth, contraception, awareness
INTRODUCTION
Many professionals from different spheres are expressing themselves concerning the issue of
adolescence and awareness of sexual and reproduction health. It is generally known that every
girl should be aware of information in the reproduction and sexual area and adequately pursue
her attitudes to these topics as it is obvious that anyone of them is a potential mother. From
the viewpoint of gaining knowledge and education, these topics are marginally discussed
within biology lessons. However there are many other sources for adolescents, not always
appropriate ones, from which they could draw. For a midwife and dispensation of her practice
in relation to this age category, there is an important task for her to provide, in an appropriate
way and approach, professional information in the area of gravidity, childbirth and
contraception. Awareness of girls in these areas is considered important in terms of their
correct decision making in the area of sexual behaviour, prevention from premature
pregnancies and by the means of it the girls could be provided by the opportunity to protect
their sexuality, build their attitudes and values in the sexual and reproduction area.
The aim of the study was to identify the awareness level of gravidity, childbirth and
contraception among girls at the age of 16-18.
METHODS
The quantitative explorative method- questionnaire of our own construction has been used. It
contained 25 items focused on surveying the source of information about gravidity, childbirth
and contraception, on the satisfaction with their quality, self-evaluation of girls about their
own awareness in these areas and on their interest in gaining more information.
98 respondents have participated in this study and the categorized criterion was age from 16.
– 18 years old. In order to verify the comprehensibility of the questionnaire items, we have
sent out a pilot questionnaire to 8 respondents. On the basis of this pilot survey, we have
modified problematic items (the introduction of a questionnaire and instructions for filling it
in). Administration of questionnaire has been proceeded personally or by intermediation of
secondary school teachers after the oral agreement with the school directors concerning the
realization of this study. The collection of empirical data was realized from January to March
79
2014. We have used a descriptive statistic to gather statistical data. Median and modus have
been determined in the questions using Likert scale. 5-point Likert scale has been used in the
questions focused on the satisfaction with the quality of information sources (1 – the least
source of information , 5 – the most quality, reliable source of information).
In order to verify the statistical hypothesis, we have used the analysis of variation or
dispersion (ANOVA) with the hierarchical organization in the programme STATISTICA 8.0.
ANOVA with the hierarchical manner of higher and lower categorical variable (hierarchically
lower variable is a subset of hierarchically higher one).
RESULTS
We have distributed 110 questionnaires in total, 100 questionnaires have been returned, but
only 98 have been finally evaluated. We have reached a recoverability of 89 %. The highest
number of respondents was in the age of 17 years old (44 %), 18 years old age respondents
represented the lowest number (25 %). Nearly a half of respondent lives in the country (47
%). The lowest representation was in the city under 20.000 inhabitants (22 %). Gymnasium
has been attended by 24 % respondents, secondary medical school by 28 %, conservatory
only by 10 % respondents, secondary vocational school with school leaving exam by 23 %
and secondary vocational school without school leaving exam by 15 % respondents. Roman
Catholic religion has been marked by 62 % respondents and 4 % has marked other religion.
Approximately half of respondents (51 %) has been engaged in the active sexual life.
Concerning the age of 16 years old respondents, 10 of them (33 %) has been engaged in the
active sexual life and 20 (66 %) has not lived the active sexual life. Concerning the age of 17
years old respondents, we have found out opposite representation – 27 respondents (63 %) has
been engaged in the active sexual life and 16 (37 %) has not lived the active sexual life.
Concerning the age of 18 years old respondents, we have detected approximately similar
representation- 14 (56 %) has lived the active sexual life a 11 (44 %) has not.
Respondents had more options of answers in the particular areas. Internet has been stated by
52 respondents (21 %) as the most common source of information concerning gravidity and
51 respondents (21 %) have stated parents as the second most common source of information.
Further on, they were gaining information from books, magazines, this was stated 43
respondents (17 %) and 34 respondents (14 %) gaining information from their female friends.
Gynaecologist as a source of information has been stated only by 22 respondents (9 %).
Concerning childbirth, parents- 52 respondents (26 %) and internet- 48 respondents, (24 %)
80
have been stated as the most common source of information. Source of information from
gynaecologist has been stated by 15 respondents (7 %). The most common source of
information concerning contraception were female friends- 52 respondents (23 %)
and internet 48 respondents (24 %). Gynaecologist as a source of information in this area has
been stated by 34 respondents (15 %).
Table 1: Sources of information
gravidity
sources
n
parents
51
female friends
34
books, magazines
43
internet
52
of school
31
gynaecologist
22
older sibling
12
other
1
∑
246
%
20,73
13,82
17,47
21,13
12,60
8,94
4,87
0,40
100
childbirth
sources
n
parents
52
female friends
26
books, magazines
26
internet
48
of school
23
gynaecologist
15
older sibling
7
other
4
201
%
25,87
12,93
12,93
23,88
11,44
7,46
3,48
1,99
100
contraception
sources
n
parents
34
female friends
52
books, magazines
23
internet
52
of school
21
gynaecologist
34
older sibling
10
other
2
228
%
14,91
22,80
10,08
22,80
9,21
14,91
4,38
0,87
100
Table 2: Satisfaction with the quality of information sources
gravidity
childbirth
sources
d
SD sources
d
parents
3,46 1,44 parents
3,53
female friends
3,09 1,24 female friends
2,88
books, magazines 3,19 1,32 books, magazines 3,07
internet
3,61 1,21 internet
3,52
of school
2,64 1,35 of school
2,82
gynaecologist
3,37 1,76 gynaecologist
3,59
older sibling
2,31 1,46 older sibling
2,24
other
3,46 1,44 other
0
Legend: d - average value; SD - standard deviation
SD
1,54
1,18
1,20
1,27
1,36
1,63
1,25
0
contraception
sources
d
parents
2,97
female friends
3,24
books, magazines 2,84
internet
3,35
of school
2,35
gynaecologist
3,86
older sibling
2,26
other
0
SD
1,55
1,31
1,28
1,28
1,38
1,56
1,46
0
In the area of gravidity, internet has been, according to the respondents, regarded as the
most quality source of information and the average value on the scale from 1 to 5 (nr. 5
represents the most quality source of information) was the highest one and it was 3,61
(±1,21). Parents have been marked by our respondents as the second most quality source of
information 3,46 (±1,44) and third place has been assigned to gynaecologist 3,37 (±1,76). In
the area of childbirth, according to our respondents, gynaecologist 3,59 (±1,63) represented
the most quality source of information, the second most quality source of information are
parents 3,53 (±1,54) and third place has been assigned to internet 3,53 (±1,27).
According to average values from gathered data related to the satisfaction, gynaecologist 3,86
(±1,56) is according to respondents, the most quality source of information about the
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contraception, parents have been stated as the second source of information 3,35 (±1,28), and
internet has been on the third place 3,24 (±1,31). The number of standard deviations in the
particular areas refer to wider variability of answers.
Table 3: Interest in more information
gravidity
sources
yes
no
∑
n
69
29
98
%
70,40
29,59
100
childbirth
sources
yes
no
∑
n
72
26
98
%
73,46
26,53
100
contraception
sources
yes
no
∑
n
73
25
98
%
74,48
25,51
100
The majority of respondents has expressed interest in gaining more information in all three
areas (gravidity 70 %, childbirth 73 %, contraception 74 %).
Table 4: Self-assessment of own knowledge
gravidity
Self-assessment
average
sufficient
insufficient
∑
n
60
27
2
98
%
61,22
27,55
2,04
100
childbirth
Self-assessment
average
sufficient
insufficient
∑
n
58
29
9
98
%
59,18
29,59
9,18
100
contraception
Self-assessment
average
sufficient
insufficient
∑
n
52
29
11
98
%
53,06
29,59
11,22
100
Respondents have evaluated their own knowledge in all three areas at most as average– about
gravidity 61 %, about childbirth 59 % and about contraception 53 %. Second, most stated
evaluation in all three areas was sufficient evaluation- about gravidity 27 %, about childbirth
30 % and about contraception 30 %. The last evaluation was insufficient evaluation– about
contraception 11 % and about gravidity 9 %.
In the table nr. 5 to 7, we are interpreting dependency between self-evaluation of respondents´
knowledge about gravidity, childbirth and contraception and main categorical variable
„keeping of active sexual life“.
Tbale 5: Dependency between self-assessment of knowledge about gravidity and keeping of
active/passive sexual life
ANOVA with hierarchical Self-assessment of knowledge about gravidity
Variable
factor
df
MS
F
p-value
of active/passive sexual life
superior
1
2,0
0,176470
0,702697
Self-assessment of respondents
slave
3
292,5
25,80882
0,012092
The influence of activity/passivity in the sexual life 0,702697 has not been confirmed (p >
0,05). Statistically significant differences (p < 0,05) have been recorded in the self-assessment
of respondents´ awareness 0,012092 about their knowledge in the area of gravidity (shares:
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above-average, average, sufficient and insufficient). They are however not dependent on the
sexual behaviour.
Table 6: Dependency between self-assessment of knowledge about childbirth and keeping of
active/passive sexual life
ANOVA with hierarchical Self-assessment of knowledge about childbirth
Variable
factor
df
MS
F
of active/passive sexual life
superior
1
2,0
0,08955
p-value
0,784281
Self-assessment of respondents
0,026853
slave
3
327,5
14,66418
The influence of activity/passivity in the sexual life 0,784281 has not been confirmed (p >
0,05). Statistically significant differences (p < 0,05) have been recorded in the self-assessment
of respondents´ awareness 0,026853.
Table 7: Dependency between self-assessment of knowledge about contraception and keeping
of active/passive sexual life
Variable
ANOVA with hierarchical Self-assessment of knowledge about contraception
factor
df
MS
F
p-value
of active/passive sexual life
superior
Self-assessment of respondents slave
1
2,0
0,240000
0,657795
3
187,5
22,50000
0,014710
The influence of activity/passivity in the sexual life 0,657795 has not been confirmed (p >
0,05). Statistically significant differences (p < 0,05) have been recorded in the self-evaluation
of respondents´ awareness 0,014710.
DISCUSSION
Awareness in each age category concerning the questions that could influence the level of
sexual and reproduction health of women and girls is very significant. In Slovakia, there is the
absence of complex research about the awareness in the area of gravidity, childbirth and
contraception concerning adolescent girls. In our study, we have focused on the awareness of
girls in the age of 16 to 18 in the above mentioned areas. We have concentrated on sources
about gravidity, childbirth and contraception, on the satisfaction level with the quality of these
sources, on the satisfaction level with the own awareness of respondents concerning this area,
as well as on the interest in increasing knowledge level of respondents in all these areas.
Analysis of results related to the information sources
83
Resulting from the analysis, we have found out that the primary source of information about
the gravidity (table 1) was internet and parents (21 %). It is an interesting finding that
gynaecologist is a source of these information only in 9 %. In the comparative study,
Chaloupková (2007, p.63) states that Czech adolescents are gaining such information most
commonly from television and magazines, as well as from parents. It results from both studies
that parents have a significant role in providing information about the gravidity. In the area of
childbirth, we could notice similar responses. The most common information sources were
parents (26 %) and internet (24 %). Female friend, books and magazines had 13 % presence
in providing information about childbirth, and only 7 % by gynaecologist (table 1).
Comparing with the Czech research, we could state that parents belong to the most common
information sources about the childbirth. Concerning Czech respondents, television and
magazines also belong to frequent information sources, similar to our group of respondents,
but not in such extent (Chaloupková, 2007, p. 63). Regarding the analysis of results related to
contraception, we have identified a mild change. Parents are not regarded as the most
common information source (only 15 %, same as gynaecologist). Our respondents are more
frequently gaining information from their female friends (23 %) and from the internet (23 %)
(table 1). Our respondents have stated their female friend (32 %), internet (22,5 %) and
parents (18,5 %) as a first source of information about contraception. In comparison to
a Czech research (Chaloupková, 2007, p.64), gynaecologist was the most common source of
information about contraception (21 %). Based on this information, we have to state that
Slovak respondents use sources that are closer and more accessible to them, but their
expertise and credibility is less satisfactory. Research that has been realized in Italy (Capuano,
2009, p.289) describes that respondents participating in a similar study preferably discuss
about the sexuality with their friends although internet is their most common information
source. Majority of them (94 %) has not gained information about sexuality from the side of
professionals.
Analysis of results related to the satisfaction with the quality of information sourcesFollowing
from the analysis of results, we have found out that gynaecologist has been evaluated by the
respondents as the most quality source of information about the childbirth 3,59 (±1,63) as
well as about contraception 3,86 (±1,56) (table 2). Internet has been determined by the
respondents as the most quality source of information about the gravidity 3,61 (± 1,21) (table
2). Parents have been evaluated positively by our respondents as a source of information in all
the areas 3,53 (±1,54). In comparison to the evaluation performed by Czech respondents in
84
the research of Chaloupková (2007, p.63), parents are evaluated more positively. Czech
respondents have evaluated information about the gravidity, childbirth and contraception from
the side of their parents as sufficient or partial, even approximately 25 % of the respondents
have not received any information about this issue from the side of their parents, so the
quality of these information was not evaluated at all. Czech research has been also focused on
the evaluation of satisfaction with the information from schools. Nearly half of respondents
has stated that information from schools about gravidity, childbirth, and contraception was
provided to them partially, 20 % respondents have evaluated this information as sufficient and
approximately 32 % respondents have stated that there was no information about this issue
from this source of information. Our respondents have not evaluated information from
schools very positively as most commonly, they have marked on the Liket scale their
satisfaction level with number 1 to 3 and average value of answers regarding their satisfaction
with the quality of sources about gravidity, childbirth, and contraception was 2,60 (±1,36)
(table 2).
Analysis of results related to the satisfaction with their own awareness
Respondents have evaluated their awareness about gravidity 61 % (table 3), childbirth 59 %
(table 4) and contraception 53 % (table 3) most frequently as average. The second most
common answer was sufficient awareness about gravidity 28 %, childbirth and contraception
30 %. The other answers have shown above-average or insufficient awareness. Chaloupková
(2007, p.63) was surveying the awareness level of respondents with the help of controlling
questions– 69 % of respondents have correctly answered questions related to gravidity.
Concerning the questions related to childbirth, 78 % respondents have answered correctly. So
in comparison to the average awareness level of 59 % in our study, it is relatively higher
value. Another interesting finding is that 84 % respondents have correctly answered questions
related to contraception. In our study, 53 % respondents have evaluated their awareness as
average, 30 % as sufficient and 11 % as insufficient. This represent significantly lower
evaluation of the awareness level in comparison to Czech respondents. Vogt and Schaefer
(2011, p.190) stated in their research carried out with 30 respondents that 77 % from them
have been informed about the advantages of contraception mainly on a good level and 23 %
have been informed very well. 79 % respondents have stated that they were informed about
the contraception risks mainly on a good level and 21 % very well.
Analysis of results related to the interest in extending the awareness
85
In average 72,5 % respondents have expressed the interest in gaining more information in the
above mentioned areas. The highest interest in the new information in the area of
contraception has been expressed by 74,5 % respondents, slightly lower in the area of
childbirth – 73 % and concerning the area of gravidity, 70 % respondents were interested in
gaining more information from this area (table 4). According to Mojzešová and team (2006,
p.73), parents do not often speak to their children about the sexuality because their awareness
level in this area is usually not sufficient. Paradoxically in our group of respondents, parents
have been stated most commonly as one of the information sources. On the other side, we
have to mention that the awareness level in this issue is most likely not sufficient as the
respondents have expressed the interest in extending their awareness in a significant extent. In
the document „The graduate profile in the curriculum of Midwifery (available on:
https://www.jfmed.uniba.sk/fileadmin/user_upload/editors/Studijne_Files/Akreditovane_SP/P
A.pdf), there are described abilities of a graduate where one of them is also an ability to
educate women clients in a way of bringing new, professional and objective information from
these areas.
Analysis of hypothesis results
Testing of statistical hypothesis has not confirmed significant influence on any of the
researched categorical variable on the self-assessment of respondents´ awareness in the area
of gravidity, parturition, and contraception (type of attended secondary school (with/without
teaching of human biology), behaviour in the area of sexual life (activity/passivity) or an
ideological opinion (respondents with/without religion). Most probably others, not considered
factors have significant influence (e.g. comparison themselves with contemporaries,
evaluation of other people). It would be interesting to compare objectively established
awareness level (awareness level could be an issue for subsequent research) with the
subjective evaluation of respondents that has been a subject of our research.
Performed tests of H0 hypothesis have not unambiguously confirmed significant difference in
the self-assessment of respondents´ awareness in the respective areas (gravidity, childbirth,
contraception). Statistically significant differences have been just recorded during the tests
focused on the influence of categorical variable „behaviour in the area of sexual life“ in all
three awareness areas. On the contrary, during the tests focused on the influence of attended
school, the difference in the self-assessment of students has been just proved in the awareness
of gravidity. These differences follow from the testing principle of variation analysis with the
86
hierarchic organization (testing of differences in the subsets, on the level of hierarchically
lower categorical variables), (tables 5 – 7). The difference in the self-evaluation of
respondents´ awareness in the respective areas (gravidity, childbirth, contraception)
independently from the influence of hierarchically higher categorial variables could be
confirmed/disproved by independent one-factor ANOVA test that has not been however
a subject of our interest.
From our perspective, it is an interesting finding of non-confirmed significance of an
ideological opinion and behaviour in the sexual life on the self-assessment awareness in the
area of contraception. Under the assumption of direct correlation between the awareness level
not surveyed by us and self-evaluation awareness in the certain area, based on our findings,
we could deduce the following:
a) formal membership of respondents to churches (we supposed the lower self-evaluation of
respondents with any religion due to the negative attitude of churches to contraception),
b) equal interest in information regarding contraception in case of actively and passively
living respondents.
CONCLUSION
Results refer to the fact that girls most frequently gain information about gravidity, childbirth,
and contraception from internet and parents. This is closely related to the opportunities of
today achievements approached in an unlimited and simple way. Gynaecologist belongs to the
common information sources, but not in such a significant extent as it would be required.
Gynaecologist is not a frequent source of information, however respondents have considered
information from this source as most quality, jointly with parents and internet. Respondents
have evaluated their knowledge as average and sufficient. However this is an inconvenient
state in relation to the importance of these information. Important and interesting finding
related to the interest in gaining new information about the gravidity, childbirth, and
contraception has been detected by 73 % girl respondents. This clearly refers to their interest
in more information as well as to potential awareness deficit in these topics as this value is
relatively high. Considering research findings, we assume to strengthen the education role of
gynaecologists and midwives, focusing on the specific age category of girls from 13 to 18
years old in all these areas. It would be necessary to extend publishing in this area in the
accessible information sources (in the printed and electronic form). Education should not only
87
be available in the cases where „it is too late“, but should provide girls relevant, professional
and true information in these areas, because self-searching and self-study on the internet does
not always provide them objective and relevant data.
REFERENCES
CAPUANO, S. et al. Sexual behaviour among Italian adolescents: Knowledge and use of contraceptives. The
European Journal of Contraception and Reproductive Health Care. 2009, vol. 14, no. 4, p. 285–289. ISSN:
1362-5187
CHALOUPKOVÁ, L. Informovanost dospívajícich dívek o tehotenství, porodu a antikoncepci. Bakalárska
práca. 93 p. Lekárska fakulta Masarykovej univerzity. 2007.
MOJZEŠOVÁ, M. et al. Sociálne aspekty predčasných gravidít. Zborník príspevkov z odbornej konferencie:
Adolescencia: aktuálne otázky predčasného a predĺženého dospievania. Bratislava: Slovenská spoločnosť pre
rodinu a zodpovedné rodičovstvo, 2006. ISBN 80-968891-5-X. p. 66-75.
LJF UK. Profil absolventa študijného programu Pôrodná asistencia. [Cit. 04-23-2014]. Dostupné na:
<https://www.jfmed.uniba.sk/fileadmin/user_upload/editors/Studijne_Files/Akreditovane_SP/PA.pdf>.
VOGT, C., SCHAEFER, M. Disparities in knowledge and interestabout benefits and risks of combined oral
contraceptives. The European Journal of Contraception and Reproductive Health Care. 2011, vol. 16,
p.183–193. ISSN: 1362-5187
CONTACT AN AUTOR
PhDr. Simona Kelčíková, PhD.
Department of Midwifery, Jessenius Faculty of Medicine, Comenius University
Malá Hora 5, 036 01 Martin, Slovakia, Europe
e-mail: kelcikovafmed.uniba.sk
88
PAIN MANAGEMENT WITH THE USE OF 3N ALLIANCE IN
PATIENTS WITH CHRONIC WOUNDS - REVIEW
Koutná Markéta, Pokorná Andrea
Koutná, M.: Clinics of Anaesthesiology, Resuscitation, and Intensive Medicine, 1st Medical
Faculty, Charles University Prague
and General Teaching Hospital Prague 2, Czech
Republic, Faculty of Health Sciences, Palacky university Olomouc, Czech Republic
Pokorná, A.: Masaryk University, Medical Faculty, Department of Nursing, Brno, Czech
Republic
ABSTRACT
Background: This study is focussed on 3 significant concepts and issues (i.e. Aliance 3N,
pain, chronic wound) each of which individually deserves an independent research and an
extensive review of available expert literature has been developed.
Methods: A bibliographic search of a clinical query has been carried out in the PICO(T)
format in 4 data bases treatment. With respect to so far insufficient resolution of these topics
by a complex approach,: CINAHL, MEDLINE,
MEDVIK, SCHOLAR GOOGLE, with
the use of a corresponding strategy including the use of referent symbols and Boole operators
in Czech and English languages in years 2000 – 2014 and completed by manual searching.
Results: In electronic data bases a total of 94 relevant sources have been found. Manual
searching brought 15 additional sources. By the first degree classification – according to the
extent and focus of each paper, as well as by the second degree classification by which papers
dealing with theoretical issues have been put aside, a total of 30 resources have been utilised
for the final analysis.
Discussion: The analysis of resources revealed that pain management is focussed on dressing
changes and on the selection of appropriate therapeutics. Only a minimum attention is paid to
general interventions of „breakthrough“ pain as well as to cyclic and non-cyclic acute pain.
Completely missing are papers focussed on the use of 3N Alliance in patients with painful
wounds.
Key Words: non healing wound, pain, 3N Alliance, intervention, review.
89
INTRODUCTION
The outcome of this study is a comparison of expert recommendations for interventions in
pain management in patients with non-healing wounds pursuant to NIC classification with
recommendations of experts from the wound management panel
This paper in its name includes three significant concepts and topics – Alliance 3N, pain and
chronic wound, each of which deserves an individually targeted research and treatment.
„Alliance 3N“ represents a large international project the first letters of which mean the
name of nursing diagnostics (NANDA
- International) connected with appropriate
interventions – Nursing Intervention Classification (NIC), plus the system of nursing care
outcomes – Nursing Outcomes Classification (NOC). Pain is a very significant diagnostic
phenomenon, which is related to disorders of most systems of the human body and which
represents both physical and mental burden in the life of patients with impacts not only on the
patient but also on his or her family environment. Last but not least, chronic (according to the
new evidence based terminology – non-healing) wounds are influenced by many factors both
at the time of their origin as well as in the course of the healing process (vascular diseases,
physical powers, surgical wounds complications, oncologic diseases) and thus they represent
a broad range of problems pertaining to the patient’s quality of life as well as to the increasing
number of socio-economic and health care problems.
An interconnection of all three above mentioned major areas represents an issue which is not
sufficiently presented in the Czech Republic. The available foreign literature is usually
dealing with isolated problems of pain related to non-healing wounds, nevertheless the issue
of Alliance 3N is absent in this context. In our opinion the topic which we have selected is
relevant, up-to-date and highly innovative. On the other hand we are fully aware of the fact
that the lack of available research resources dealing with these problems in their complexity
may be a source of difficulties in formulating theoretical basis.
The objective of our search strategy has been to find studies targeted on the evaluation of
utilising Alliance 3N in the pain management in patients with chronic, non-healing wounds
and on the basis of acquired information to draw up a set of nursing interventions with
corresponding recommendations for the clinical practice, followed by a verification of their
efficacy. The final goal of our efforts should be the improvement of nursing care without
overburdening the health care professionals.
90
METHODS
The first step in search strategy is the definition of the issue to be studied and the appropriate
reference literature to be searched for. The question was asked in the PICO (T) format with
contents of individual categories determined – see Table no.1.
Table No. 1 Research Topic in PICO(T) format
Fundamental Research Topic:
P
O
Problem/population
Patient
Intervention, subject
interest
Comparison of
interventions or groups
Outcome
T
Time
I
C
What are the interventions of nurses in patients in pain with a chronic/nonhealing wound?
How to describe the group?
Patient in pain with a non-healing wound
May be deemed the major
intervention?
Is there any other intervention and
what is the difference?
What do we want to change, what
do we want to achieve?
For which time period will be
information data collected?
Nurses ´s intervention according to NIC
Comparison of the existing nonpharmacologic nursing interventions
Pain management – appropriate nursing
interventions
2000 – 2014
The next step for efficient search is the selection of appropriate key words. In English they are
the following: chronic wound*, non –healing wound*, pain, intervention, pain assessment,
Alliance 3N, in Czech (for comprehensive approach): chronická or nehojící se rána, bolest,
intervence, hodnocení bolesti, Alliance 3N. Non-healing wounds are defined as ulcers,
including sore ulcers (pressure sores). The extended search included the following words:
ulcus, pressure sore*, decubitus; in Czech we searched for terms dekubitus, proleženina,
dekubitární vřed. We have used the extending search strategy including synonyms with an
asterisk as a referent symbol, which enables extended search based on the root of the searched
word.
The individual words have been applied according to Boole operators. Subsequently we have
used the following connections:
 chronic OR non-healing wound*AND pain* / chronická OR nehojící se rána AND bolest*
 nurse intervention*AND pain / intervence sester* AND bolest
 nurse AND pain assessment / sestra* AND hodnocení bolesti
 Alliance 3N AND pain/ Alliance 3N AND bolest
Based on the above mentioned key words a bibliographic search was implemented which was
then compared with a search of the National Medical Library. Data from four data bases (data
bases were selected according to their availability) were acquired. The search objective was to
find relevant information which had been published in the time period extending from year
2000 through to year 2014 (T – time concept of PICO clinical queries) in papers containing
91
full text as well as an abstract, focussed on adult subjects and published in English, Czech and
Slovak languages.
The other significant literary resources have been acquired by manual searching.
By first degree classification all articles without direct connection with pain management with
the use of non-pharmacological means (such as vacuum assisted therapy), others which used
physical methods to manage pain, those which dealt with prevention, acute pain, intensive
care and pharmacological methods, use of therapeutic wound dressings, including abstracts
with no full text available have been laid aside. The second degree classification excluded
duplicate papers and texts which cited secondary sources as well as ideas of other authors also
included in the list of texts. Theoretical works were also laid aside. The second degree
classification
provided
sources
which
included
reviews,
evidence-based
expert
recommendations and research works with respect to IMRaD methodology (works in
extenso).
At first the following key words have been used: chronic wound, non-healing wound and
pain. On the basis of these key words 280 references have been found and 19 full texts
remained from CINAHL data base, out of 166 full texts from the Medline data base 164 were
laid aside by the first degree classification; the Medline data base provided a total of 585
original texts, however, after first degree classification only 23 texts remained for our
purpose.
On the basis of our key words the Google Scholar data base showed 11300
references, but unfortunately most of them as abstracts only. From a total of 9 full texts 8
were laid aside and the remaining one paper was used for the related analysis.
For the topic „Nurse intervention in pain management related to chronic, non-healing
wounds“ the used key words were: pain, chronic/non-healing wound and intervention. Only a
minimum of references were found for this problem both in English and Czech languages.
From all available data bases only 30 relevant works have been assessed and selected for the
subject of a thesis.
Additional 15 suitable works have been acquired by manual searching. References obtained
by manual searching include sources acquired directly during our presence at various
Symposia, by studying expert Czech literature or by oral peer recommendations, in
compliance with methodological instructions pertaining to bibliographic search strategies.
With respect to the intention to further specify literary resources in accordance with the
92
phenomenon dealt with in each chapter, a subsequent classification has been carried out
according to the nature of the resource – i.e. does it pertain only to a non-healing wound, or
pain management, types of pain, pain incidence, pain interventions, or only to basic (input)
information. The purpose of the assigned search by the National Medical Library was to
compare or complete the sought-after texts.
RESULTS
The analysis of 11 sources (reviews) and of additional 19 expert texts from three four bases
showed that the contents of the individual sources are focussed more on the issue of pain
incidence in connection with non-healing wounds of various aetiologies, on the pain
characteristics and its manifestation and on pain management.
One third of papers is related
to the impact of pain on the quality of life of patients (see Table No.
2). Only 4 articles
discussed nurse´s interventions but merely two of them described particular specific
procedures used in nursing care.
As issues from the final assessment of the complete literary search, the articles are chiefly
focussed on pain affecting interventions in the course of dressing changes and on selecting
therapeutic materials. Just a minimum of attention is paid to general interventions of the
“breakthrough“ pain, non-cyclic and cyclic pains. Articles dealing with the usage of 3N
Alliance for patients in pain caused by a wound are entirely absent.
Table 2: A brief overview of the focus of the analysed sources
Review + meta – analysis
11
Randomised double - blind study
Synopse
2
3
Case and control study
8
Cross – sectional studies
Focus group
Guideline
4
1
1
Pain assessment
Pain, Wound and Quality of Life
General intervention
Intervention of nurses
Incidence of chronic wounds
Stress, pain, wound
Pain management
Types of pain
Education in pain and wound
Quality of Life and intervention of nurses
Pain assessment and intervention of nurses
Types and causes of pain
Pain at dressing changes 2x
Comparison intervention of nurses
Quality of Life
Care about patients with pain in the Community
Pain assessment
Nurses attitudes to the pain management
Quality of Life and leg ulcers
Pain Management
93
DISCUSSION
The time span of the bibliographic search pertaining to „Pain Management in Patients with
Chronic Wounds included 14 years (2000 – 2014). This decision of the authors was based on
the fact that the foreign publications dealing with topics of pain and chronic wounds have not
been too frequent and in the local literature there are only several papers which have appeared
within the last few years (Stryja, 2010; Pokorná, Mrázová, 2012)
The individual interventions within the framework of NIC classification related to pain
management are focussed generally on pain in patients with diseases of various etiology
(Bulechek et al. 2013, p. 261). The other two relevant papers potentially complementing NIC
which have been found, are focussed on dressing changes and reducing or eliminating pain
connected with this procedure, including the strategy of approach to the patient. The answer
to the question whether some activities described in the three sets are not duplicated may be
deemed the comparative review of activities in Table 3. Generally may be stated that in
resources analysed in detail a consistency has been found which presents 4 key areas of
activities.
The area on the patient's cooperation:
−
Consider the patient's willingness to participate, ability to participate, preference,
support of significant others for method, and contraindications when selection a pain
relief strategy (Bulechek, 2013)
−
Involve and empower the patient (Briggs, 2002)
The area analgotherapy – application painkiller:
− Medicate before an activity to increase participation, but evaluate the hazard of
sedation (Bulechek, 2013).
−
Consider pre-medicating before dressings (Briggs, 2002).
−
Consider preventive Analgesia (White, 2008).
The area psychological support of the patient:
-
Encourage patient to discuss the pain experience, as appropriate notify physician if
measures are unsuccessful or if current complaint is a significant change
form
patient´s past experience of pain (Bulechek, 2013)
-
Be proactive with The patient- encourage real-time verbal feedback and incorporate
the use of pain assessment tools (White, 2008).
94
The area focus on the use of relaxation of the techniques:
− Teach the use of nonpharmacological techniques (e.g., biofeedback, TENS, hypnosis,
relaxation, guided imagery, music therapy, distraction, play therapy, activity therapy,
acupressure, hot/cold application , and massage) before, after, and if possible, during
painful activities, before pain occurs or increases, and along with other pain relief
measures (Bulechek, 2013)
− Encourage patient controlled techniques, e.g. to focus on slow rhythmic breathing or
listening to music. (Briggs, 2002)
Conversely file NIC activities complement the four „specific“ activities from two sources
authors found Briggs, Torra, (2002) a White, (2008):
-
Offer patients 'time out' during procedure
-
Choose an appropriate non-stressful environment
− If possible, give a prefer to non – adherence dressings
− Select the primary dressing, which can remain on the wound for extended periods, if
possible
Table 3: Comparison of the three sources focused on interventions
NIC, Bulechek et al.
Perform a comprehensive
assesment of pain to include
location
Observe for nonverbal cues
of discomfort, especially in
those unable to
communicate effectively
Assure patient attentive
analgetic care
WUWHS, in Douglas, 2004
Involve and empower the
patient
White, 2008
Consider preventive
Analgesia
Promote stress-free
environment
Choose an appropriate
non-stressful
environment
Be aware of patient's current
pain status
Use terapeutic
communication strategies
Avoid pain triggers and
where possible, use pain
reducers
Explore patients knowledge
and beliefs about pain
Adopt a calm and confident
approach
Consider cultural influences
on pain response
Consider pre-medicating
before dressings
Assure position the
patient to minimise
discomfort and
avoid unnecessary
contact or exposure
Explain to the patinent
in simple terms the
proposed treatment
procedures
Assess the need for
Skilled or unskilled
assistance, such as
help with
handholding
Avoid any unnecessary
Stimulus to the
95
Determine the impact of the Encourage patient controlled
pain experience on quality of techniques, e.g. to
pastlity of life
focus on slow rhythmic
breathing or listening to
music
Explore with patient factors
that improve /worsen pain
Evaluate with the patient and
the health care team
Assist patient and family to
seek and provide support
Wound such as
prolonged exposure
while waiting for
specialist advice, and
handle wounds gently to
avoid tactile pain.
Be proactive with
The patient- encourage
real-time verbal
feedback
and incorporate the use
of pain assessment tools
Offer patients 'time out'
during procedure
Avoid any unnecessary
stimulus to the wound, in
particulac avoid wiping
across the wound
Observe wound and
surrounding skin for signs of
any local factors causing
pain
CONCLUSION
On the basis of a review oriented to pain management in patients with non-healing wounds
with the utilisation of the fundamental clinical PICO query, only two relevant papers offering
recommendations pertaining to interventions reducing or eliminating pain during dressing
changes have been found from the total of 30 analysed sources. Both these documents have
been compared with NIC (Nursing Intervention Classification) 2013 version
(Bulecheck,
2013, p. 261). Most interventions in the compared sources (Briggs et al., 2002; White, 2008)
are not duplicated; on the contrary, their contents complement the NIC interventions.
The key to the effective wound management in patients in pain related to the non-healing
wound is a detailed assessment of all of the underlying factors including the cause of pain.
The anamnesis basis becomes the pain assessment together with the use of the so-called pain
alphabet, as the intervention classification recommends on the general level. Various
etiologies of non-healing wounds are known by their triggers as well as by the defensive
mechanisms (ischaemia – more severe pain at low temperature, or in elevated position of the
affected body part etc.). The strategy of pain reduction or elimination is focussed on the
individual interventions of nurses which are subsequently applied according to causes of pain
or to the trigger factors. All interventions must be implemented in collaboration with the
96
patient, with the use of all available medical history information and patient´s pain experience
as well as with the previously used solutions of pain reduction. This fact is highlighted by
NIC and the other two recommendations by wound management experts summarising
recommendations for pain elimination in patients with non-healing wounds. Our paper shows
that expert literature dealing with nursing interventions (NIC) and pain solutions in patients
with chronic wounds is scarce in the Czech as well as in the foreign data bases. The
appropriate resolution would be a development of an original algorithm in which
interventions will be interconnected within the NIC framework and with recommendations
by professional associations (Bulechek, 20013, Briggs et al., 2002, White, 2008).
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CONTACT AN AUTOR
Mgr. Koutná Markéta
Klinika anestezie, resuscitace a intenzivní medicíny, VFN
U Nemocnice 2, Praha 2, PSČ 12808
Email: [email protected]
Tel: +420 602 380 189
98
NUTRITIONAL BEHAVIOR IN RELATION TO OVERWEIGHT
IN POPULATION OF SCHOOL-AGED YOUTH
Kožuchová Mária, Bašková Martina
Kožuchová, M.: Department of Nursing, Faculty of Health Care, Catholic University
Ruzomberok
Bašková, M.: Institute of Midwifery, Jessenius Faculty of Medicine in Martin, Comenius
University in Bratislava
ABSTRACT
Background: The aim of the study was to analyze the factors of nutritional behavior in 11-,
13- and 15-year old schoolchildren in relation to Body Mass Index (BMI).
Methods: The international questionnaire produced for the needs of HBSC study (Health
Behavior in School Aged Children) was used. The sample consisted of 1,187 pupils (620 girls
and 567 boys) aged 11, 13 and 15. The data were collected in 25 elementary schools and two
eight-year high schools in Middle Slovakia from May to June 2010. Statistical analysis of the
hypotheses was processed using STATISTICA software. Significant interaction of two
variables was evaluated using chi-quadrat test.
Results: Significant differences between overweight and normal-weight children were
identified within the following: breakfast on weekends (p = 0.042), consumption of sweets (p
= 0.016), reduction of body weight (p = < 0.000005). We state that eating habits of children in
relation to the mentioned indicators are dependent on overweight. There were not found any
statistically significant differences in other indicators of nutritional behavior: breakfast on
weekdays (p = 0.341), consumption of fruits (p = 0.952), consumption of vegetables (p =
0.351), consumption of sugary drinks (p = 0.924).
Conclusions: It is obvious from the results of the study that more remarkable eating-regime
deficiencies which can have unfavorable impact on children´s health prospects were observed
especially in overweight children compared to normal-weight children. The targeted
recommendations to improve their eating habits were based on the above mentioned findings.
Key Words: nutritional behavior, overweight, Body Mass Index, school-aged youth, HBSC.
99
INTRODUCTION
Overweight and obesity is one of the most common metabolic diseases in all age categories
which has become a global epidemic problem. The occurrence of child overweight and
obesity is increasing not only in the economically developed countries, but also in the
underdeveloped countries. Unfortunately, the Slovak Republic is no exception (Petríková
Rosinová, Bočáková 2008, p. 16). There is an increasing incidence in children and
adolescents worldwide while a rapid growth has been observed mainly in the U.S. (Mackay,
Duran 2007, p. 2). According to the statistics of the World Health Organization, in the
European Union more than 14 million schoolchildren are overweight, out of which 3 million
are obese. Annually, there is an increase by approximately 400,000 overweight children, out
of which 85,000 children are obese. In the Czech and Slovak population, overweight is stated
in 13 % of boys and 12 % of girls, obesity in 6 % of boys and 5.6 % of girls (Hlavatá 2007, p.
13). This unfavorable trend is determined by a significant drop in physical activity, but also
by unfavorable eating habits. Jurkovičová (2005, p. 128) states that eating habits of children
and young people are improper. They more often consume foods which should be restricted
most, which, along with a sedentary lifestyle, leads to the development of obesity.
Overweight and obesity have its economic, health and social negatives (Neumark-Sztainer et
al. 2002, p. 123). Regularity in eating habits is of great importance in nutrition (Dimunová,
Mechírová 2013, p. 701). Babinská et al. (2007, p. 217) state that epidemiologic researches
have proven correlations between irregular eating regime and increased risk of obesity. The
irregular food intake also negatively affects mental activity having an impact on child´s
prosperity and behavior at school.
The HBSC study is a cross-national study that started as an initiative of three countries in
1983 (UK, Finland and Norway). The objective is to monitor health, health-related
schoolchildren´s behavior in their social context. The contribution presents selected findings
of the HBSC research related to the factors of nutritional behavior in 11-, 13- and 15-year old
schoolchildren in relation to Body Mass Index (BMI).
METHODS
The HBSC study was adopted by the World Health Organization and now there are more than
40 collaborating countries including Slovakia. The international questionnaire produced for
the needs of the HBSC study, which had been translated into Slovak in a standard way, was
used for the data collection. The questionnaire was distributed in school classes by a team of
100
trained administrators. The individual schools were selected from the list of all elementary
schools and eight-year high schools in Slovakia provided by the Institute of Information and
Prognoses of Education by random sampling carried out in the HBSC Data Management
Centre (Bergen, Norway). The data collection was realized in 25 elementary schools and two
eight-year high schools in Middle Slovakia from May to June 2010. The schools were
contacted by telephone and asked for consent to participate in the international HBSC study.
During the phone call with the schools, which agreed with the participation, we obtained
approval of the school management and selected by random sampling the particular classes, in
which the data were collected. The legal representatives of the respondents were acquainted
with the research so that they could express their disagreement with the participation. The
participation was voluntary.
For the purposes of the study there were analyzed demographic factors (sex, grade, age) and
the relationship between nutritional behavior (breakfast on weekdays, breakfast on weekends,
consumption of fruits, vegetables, consumption of sweets, sugary drinks, reduction of body
weight) and respondents´ BMI. Significant interaction of two qualitative variables was
evaluated using chi-quadrat test. Hypotheses were tested at the significance level p = 0.05.
The STATISTICA software was used for the statistical analysis.
RESULTS
The research sample was composed in accordance with the criteria of HBSC study and
stratified by regions and school types (elementary school, eight-year high school). The data
were acquired about 11-, 13- and 15-year-old schoolchildren representatively for the
population in Middle Slovakia (Zilina and Banska Bystrica region). In Zilina region there
were 474 respondents and in Banska Bystrica region 713 respondents. In total, the group
consisted of 1,187 pupils (620 girls and 567 boys). Respondents who met the following preset
criteria were included in the research group:
age (11-, 13- a 15-year-olds),
the respondent is a pupil of elementary school (5th–9th grade) + equivalent in eight-year high
school (prima–kvinta),
an informed parent´s consent and participation in respondent´s research,
willingness to collaborate.
101
Using chi-quadrat test we probed whether there are statistically significant relations between
nutritional behavior (breakfast on weekdays, breakfast on weekends, consumption of fruits,
vegetables, consumption of sweets, sugary drinks, reduction of body weight) and BMI values
of the respondents. The results we found are presented in Tables 1 and 2.
Table 1 Relation between nutritional behavior and BMI values of respondents
χ2
6.340
15.564
105.152
Nutritional behavior
Breakfast on weekends
Consumption of sweets
Reduction of body weight
P
0.042
0.016
< 0.000005
The statistical analysis proved that there are significant differences in the following indicators
of nutritional behavior (breakfast on weekends: p = 0.042, consumption of sweets: p = 0.016,
reduction of body weight: p = < 0.000005) between overweight children and normal-weight
children. The overweight children have breakfast on weekends just on one weekend day
almost twice more often (16.09 %) compared to normal-weight children (8.90 %). The
normal-weight children have breakfast on both weekend days more often (87.67 %) compared
to overweight children (78.16 %). Regarding the consumption of sweets, normal-weight
children prevail in more frequent consumption of sweets (5 – 6 days a week, once daily each
day, more than once each day). Overweight children prevail in less frequent consumption of
sweets (less than once a week, once a week and 2 – 4 days a week). The both groups of
children consume sweets mostly 2 – 4 days a week: 25.03 % of normal-weight children
and 29.76 % of overweight children. Regarding the reduction of body weight, more than three
times more normal-weight children (56.87 %) than overweight children (15.91 %) are
satisfied with their weight. Almost three times more overweight children (51.14 %),
compared to normal-weight children (18.78 %), state they should lose some weight. Almost
three times more overweight children (32.95 %) than normal-weight children (11.23 %)
definitely agree with dieting.
Table 2 Relation between nutritional behavior and BMI values of respondents
χ2
5.656
1.605
6.683
1.954
Nutritional behavior
Breakfast on weekdays
Consumption of fruits
Consumption of vegetables
Consumption of sugary drinks
P
0.341
0.952
0.351
0.924
It was found that there are no statistically significant differences in nutritional behavior
between overweight children and normal-weight children in the following indicators:
102
breakfast on weekdays (p = 0.341), consumption of fruits (p = 0.952), consumption of
vegetables (p = 0.351), consumption of sugary drinks (p = 0.924).
DISCUSSION
Nutrition of children and young people favorably affects health, creates conditions for the
achievement of a harmonious and versatile child´s development. Proper nutrition plays from
a very early age a significant role in the prevention of various injuries to health which often
appear only in adulthood. Therefore, it is important to pay attention to the fact that children
should acquire proper eating habits which are an effective prevention of nutritional diseases in
adulthood.
Kovács et al. (2008, p. 23) state that studies focused on the evaluation of eating regime pay
most attention to breakfast. One of reasons is the fact that eating breakfast irregularly belongs
among the most frequent deficiencies in children´s eating regime. Regular breakfast eating is
an integral part of a healthy diet of children (Keski-Rahkonen et al. 2004), it has also
a positive impact on children´s health and wellbeing (Rampersaud et al. 2005, p. 743).
Babinská et al. (2007, p. 218) state that a lot of researches draw attention to the risks related
to breakfast skipping and bring arguments in favor of its regular consumption. In children
eating breakfast we can observe a better nutritional composition of food and a more balanced
intake of nutrients compared to children skipping breakfast. In view of the increasing
incidence of child obesity, attention should be paid to the correlations found between
breakfast eating and the risk of obesity. In the study we did not find statistically significant
differences between breakfast eating on weekdays and BMI values (p = 0.341) (Table 2). On
the contrary, we found a significant relation between breakfast eating on weekends and BMI
values (p = 0.042). Normal-weight children (87.67 %) eat breakfast on both weekend days
more often than overweight children (78.16 %) (Table 1). Several studies (Berkey et al. 2003;
Ušáková, Pekařová 2011; Vanelli et al. 2005) draw attention to this fact, since their studies
confirmed the relation between the absence of breakfast and the overweight of pupils. In
obese children there is observed a more frequent skipping of breakfast, fruits and vegetables
and postponement of the last meal till late evening hours. Therefore, such an eating regime is
considered to be one of risk factors that can contribute to obesity (Babinská et al. 2007, p.
218). On the contrary, children eating breakfast regularly have a lower probability of obesity
(Boutelle 2002). Regarding the consumption of fruits and vegetables, we did not find
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statistically significant differences between overweight children and normal-weight children
(consumption of fruits: p = 0.952), (consumption of vegetables: p = 0.351) (Table 2).
A specific issue in child nutrition in school age and adolescence is the excessive intake of
certain types of foods, such as sweets and sugary drinks which leads to the acquisition of
improper eating habits, negatively influences health and causes an increased risk of dental
problems. Nevoral et al. (2003, p. 131) state that drinking sugary beverages in combination
with sweet foods leads to insulin egestion and subsequent rapid decrease of blood sugar which
can be manifested as child´s attention deficit disorder and fatigue. Saccharides consumption is
high, sweets being consumed excessively. We did not find statistically significant differences
in consumption of sugary drinks between overweight children and normal-weight children (p
= 0.924) (Table 2). The results of our study related to the consumption of sweets prove that
normal-weight children prevail in more frequent consumption of sweets (once a day each day
or more than once a day). Overweight children prevail in less frequent consumption of sweets
(once a week or less than once a week). These differences are statistically significant (p =
0.016) (Table 1). The presented results related to the consumption of sweets are compatible
with the study results of Hassapidoua et al. (2006). On the contrary, in the study of
Gongolová and Zavadilová (2013, p. 515), more than one third of respondents (35 %)
consume sweets each day (especially overweight and obese children) and more than 50 % of
children prefer sugary drinks. In the study of Nicklas et al. (2003), which was based on
a sample of 1,562 children, the consumption of sweets positively correlated with the
incidence of overweight (p = <0.001). Consumption of energy-rich and nutrients-low food
such as sweets can disturb the regularity of eating regime and the intake of proper and full
meals (Babinská et al. 2007, p. 218). Numerous studies (Babinská et al. 2007, p. 218) have
drawn attention to the rising trend of sugary drinks intake and confirm its relation to the risk
of obesity. However, if children might choose they would often prefer a sugary beverage of
Coca-Cola type to milk, fruit teas and juices containing vitamins (Nevoral et al. 2003, p. 131).
The preference of sugary beverages and cola drinks containing caffein and high in sugar
unfavorably affects children´s drinking regime (Liba 2010, p. 54).
Dieting among adolescents is relatively widespread and, according to White (2000, p. 77), has
become a certain standard in society. Researches focused on dieting in pursuit of weight
reduction confirm that being on diet is widespread especially among women (Blood 2005, p.
129). Starting any diet increases the risk of eating disorders in adolescent girls. Extreme
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methods of slimming down can have unfavorable physiological effects (Daee et al. 2002).
Dieting and a desire to lose weight is often caused by unhappiness about one´s own figure. In
the reduction of body weight we found statistically significant differences between the
reduction of body weight and BMI values of the respondents (p = < 0.000005). More than
one half of normal-weight children (56.87 %) compared to overweight children (15.91 %) are
satisfied with their weight. More than one half of overweight children (51.14 %) compared to
normal-weight children (18.78 %) state that they should lose some weight (Table 1). The
study of Jones et al. (2001) did not prove this fact. In the study of Schur et al. (2000), 50 % of
children state that they are not satisfied with their figure and want to weigh less and 16 %
state that they have tried to lose weight.
A child acquires eating habits particularly in the home environment by observing and copying
nutritional behavior of other family members. Proper eating habits in a family are the best
example and the most proven educational means in proper nutrition.
CONCLUSION
In child and adolescent age, proper nutrition is the key determinant of growth, development
and prevention of nutritionally induced diseases. The consequences of improper nutritional
attitudes appear also in adulthood. Eating habits of children and youth imply exceeding total
intake of energy, imbalance of food composition and irregularity in eating regime. In our
research we observed the relation of nutritional behavior and Body Mass Index. The findings
presented in the study concretize substantial deficiencies in children´s nutrition that we
observed particularly in overweight children compared to normal-weight children. First of all,
these are absent breakfasts on weekends, consumption of sweets in almost one third of
overweight children two to four times a week. These deficiencies can unfavorably influence
health prospects of children. The targeted recommendations to improve their eating habits
were based on the above mentioned findings, where nursing has a great importance according
to Raková, Prokopová (2008) in terms of the implementation of educational interventions in
clinical practice. The intervention actions, in particular the awareness of the principles of
proper nutrition, are a precondition of the prevention of health problems.
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Ošetřovatelství a porodní asistence [online]. [Ostrava (CZ)]: Lékařská fakulta Ostravské univerzity,
2013. vol. 4, no. 4, p. 700 - 707 [cit. 2014-12-09]. Dostupné z:
http://periodika.osu.cz/osetrovatelstviaporodniasistence/dok/2013-04/8_dimunova_mechirova.pdf.
GONGOLOVÁ G, ZAVADILOVÁ V. Obezita u dětí ve školním věku. Ošetřovatelství a porodní asistence
[online]. [Ostrava (CZ)]: Lékařská fakulta Ostravské univerzity, 2013, vol. 4, no. 1, p. 513 - 519 [cit. 201403-09]. Dostupné z:
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HASSAPIDOU M. et al. Energy intake, diet composition, energy expenditure, and body fatness of adolescents in
northern Greece. Obesity. 2006, vol. 14, no. 5, p. 855 - 862. ISSN 1930-7381.
HLAVATÁ A. Obézne dieťa v ambulancii lekára pre deti a dorast. Pediatrická prax. 2007, roč. 8, suppl. 1, s. 12
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CONTACT AN AUTHOR
PhDr. Mária Kožuchová
The Catholic University in Ruzomberok
Faculty of Health Care, Department of Nursing
Námestie A. Hlinku 48
034 01 Ružomberok, Slovak Republic, Europe
email: [email protected]
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NEWLY GRADUATE NURSE IN INTENSIVE CARE: THE
TRANSITION SHOCK FROM COMING INTO PRACTICE
Knechtová Zdeňka, Burešová Jana
Knechtová, Z.: Department of Nursing, Faculty of Medicine, Masaryk University, Brno
Burešová, J.: Intensive Care Unit, The University Hospital Brno
ABSTRACT
Background: The shock caused by the transition from education to practice is also
characterized as a natural, acute and dramatic phase of the adaptation process of newly
graduate nurses coming into professional life. The main aim of this research is to map the
transition period of fresh graduates of university nursing programmes starting their first
employment in intensive care units and resuscitation care units.
Methods: For the collection of data we chose the qualitative approach. The collection of data
was done by means of writing an essay. Data were submitted to inductive content analysis,
carried out by two independent coders. The group researched consisted of 31 graduates
holding a master’s degree in nursing and working in intensive care and resuscitation care units
shortly after finishing their adaptation process.
Results: Results provided by the qualitative research revealed that the experience of new
graduates starting to work in intensive care and resuscitation care units includes a broad range
of factors making their experience either easier or more difficult. Those factors include
mainly interpersonal relationships, knowledge, skills, and education.
Conclusion: Feelings accompanying the period before and during the beginning of a new
employment in intensive care and resuscitation care units and factors making the transition
period from school to practice easier or difficult have been described. Our research also
includes personal recommendations provided by respondents how to get easier over the shock
from coming into practice.
Key Words: Transition shock, graduate, intensive care, nursing.
INTRODUCTION
The shock from transition from education to clinical practice is characterized as a natural,
acute and dramatic phase of the adaptation process of a graduate starting his professional life.
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The shock from transition into practice can cause major changes in the life of the individual
and his close relatives and friends, bringing about possible consequences showing on their
health and well-being (Schumacher, Meleis, 1994, p. 119-127). The shock includes elements
such as shock from reality, the transition from the protected environment of school to an
unknown environment, cultural shock and acculturation stress, as well as problems related to
the adaptation to the professional role, growth and progress (Duchscher, 2009, p. 1103-1113;
Duclos-Miller, 2006, p. 196). The transition of graduates from school to practice is often
stressful, frustrating, discouraging and full of disillusions. Prior to starting their employment
graduates often feel euphoric and excited. During their studies they get idealistic ideas
influencing their expectations (Parker et al., 2014, p.150-156). The bigger the ideals that they
will be able to apply everything they learned in practice, the stronger the tendency to
experience a shock from the reality. The extent to which the graduate’s shock will manifest
itself depends to some extent on his previous life experience, the maturation of his skills and
the speed of their going through which is expected from him.
Duchscher (2008, p. 441-450) also states that major changes in personal as well as in
professional life occur during the first three months following the beginning of the
employment, during which the energy of the graduate is used due to adaptation to new roles
and responsibilities and to accept the differences between the theoretical knowledge gained at
school and the practice where emphasis is placed on team cooperation. The end of these three
months is often marked by feelings of exhaustion and isolation, arising from disorientation,
confusion and total chaos following their newly found reality.
If the graduate chooses as his workplace the department of intensive care, he or she should
realize that nurses working in intensive care deal daily with serious health conditions, death,
angry and/or grieving families, and with conflicting demands at their work place (GroharMurray, Dicroce, 2003, p. 317). The main goal of our research was to map the transition
period of nursing studies graduates from studies to their first employment taking place at
intensive care units (intensive care and resuscitation care units).
In the frame of our research we set four research goals which mirrored our research questions.
1st goal: To find out what is the experience of nursing studies graduates with the initial period
in their first employment.
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2nd goal: To find out which factors influenced the period of going through of nurses in their
first employment.
3rd goal: To find out how the graduate’s personal life was affected by his transition from
studies to practice.
4th goal: To find out what recommendations the respondents would give to the graduates to
make their transition from studies to practice easier.
The research sample consisted of 31 respondents (30 females, 1 male) who experienced the
transition period from education to clinical practice at intensive care and resuscitation care
units and had finished their adaptation process. The average length of their clinical practice
was 26 months.
METHODS
Due to the goals set and research questions defined we chose qualitative research approach.
The collection of data was done by means of an essay. The instructions regarding the essay
included fields defined on the basis of analysis of data collected during the pilot study
(Assignment: Describe your feelings, practice and experience, then express your
recommendation, etc.). The collection of data was commenced by approaching friends via email and social networks. Further respondents were recommended by the method of snowball
sampling following the initial phase of data collection. E-mail with instructions regarding the
essay was sent to respondents who agreed to participate in the research. According to
Miovský (2006, p. 131-132), a qualitative research should be carried on until the data are
saturated. Based on this recommendation, 31 essays were analyzed prior to stopping the data
collection. Essays were submitted to inductive content analysis carried out by two
independent coders. In the first step, both coders went through all 31 essays, and then they
suggested categories enabling us to assess the essays. Open coding made it possible to
thoroughly study the data by means of breaking the text down into separate parts carrying
certain meaning. Codes were assigned to sentences on the basis of their meaning content.
During the research process coders were asking questions: “What does it seem to be about?”
or “What does it say about?” (Strauss and Corbin, 1999, p. 42-52; Miovský 2006, p. 241).
In the second phase separate categories were compared and a system of categories to which
both coders agreed was developed. All essays were then assigned their codes and codes were
grouped to higher order, i.e. to categories according to their similarity or affiliation to a
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certain phenomenon. In total, eight categories showing mutual relations were defined. An
analytical picture of transition from education to clinical practice was created on the basis of
mutual relations and correlations among categories detected. The analysis itself was
performed manually using the pencil-paper method with codes differentiated by colour. Each
essay was marked by a number from 1 to 31. The shortest essay consisted of 88 words, the
longest of 1160 words. On average the essays consisted of 312 words.
RESULTS
The methodology described above was used for classification of topics the respondents were
addressing in their responses.
1. The feelings before starting clinical practice
Respondents were stating that they were looking forward to commence their employment,
seen as a way to achieve independence, both at work and in personal life, and to be financially
independent from their parents. Another reason was that they like working with people, it
brings them fulfilment and is their dream job. Other important reasons were gaining the status
of a nurse, finishing their studies, using the knowledge and skills gained at school, their wish
to obtain new knowledge and skills, getting to know new people and real practice, and last but
not least getting the job itself.
The survey also reveals that some respondents didn’t look forward to begin their employment.
The reasons were bad experience during their practical training and being concerned about
lack of their theoretical and practical skills. Respondents also worried or felt uneasy about the
execution of new activities at their workplace and about being accepted by the work team.
2. The development of getting into practice.
Only minimum of respondents described the initial phase of their work practice as easy,
stating they were happy to gain new information and to work with their supervisor and the
team.
Most respondents evaluated the initial phase as difficult. Among reasons stated was receiving
an immense amount of information over a short period of time. Respondents also mentioned
as stressful the increase of responsibility and their fear of failure.
Some respondents also mentioned that the period of transition from school to clinical practice,
was made more difficult by the team of their co-workers, or by their behaviour which differed
111
compared to how they used to know them from their practical training. Respondents
experienced fear, stress, strain, lack of time, increase of responsibility, and a feeling that
things are getting over their heads, which influenced their mental state.
Some essays contained elements of both easy and difficult development of settling at work.
On one hand, respondents experienced as negative the reception of huge amount of
information over a short period of time and their inability to organize their work. On the other
hand, the course of this period was made easier by a good team of co-workers, being happy to
work with people and finding a meaning of their work, etc.
3. Factors influencing the transition from education to clinical practice.
The most important findings in this area regarded interpersonal relationships at the workplace:
majority of respondents stated that being accepted by their colleagues at their workplace was
a factor which made the transition easier. They evaluated positively the opportunity to ask
their colleagues questions, to ask for help or an advice in new situations. From the analysis it
emerged that if the respondents were accepted well by the team at their workplace, the
transition from education to clinical practice was much easier. Respondents had a feeling that
the team is standing behind them and is supporting them.
Interpersonal relationships were stated by the respondents as another important factor making
the transition from education to clinical practice more difficult. Respondents mentioned
superior attitude and unpleasant or reluctant behaviour if they needed help from the team. To
explain these phenomena respondents stated following aspects: generational gap, their higher
education, bad relationships among the colleagues before their start of clinical practice.
4. The best experience during the transition period
The best experience falling into this category was usually connected to appreciation or
positive feedback, especially in form of praise or acknowledgement both from the patient or
superior worker.
Respondents also considered as important the development of their skills and knowledge
which gave them feeling of well performed work and bigger independence at work.
5. The worst experience during the transition period
The worst experience stated by respondents as connected to the start of their clinical practice
was usually linked to difficult and new situations. Respondents felt overwhelmed, unprepared
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and worried whether they will be able to handle the situation. Situations related to death of a
patient were also seen as very difficult.
6. Impact on private life
Respondents considered shift work and lack of free time as aspects having negative effect on
their personal life. Some respondents also mentioned bringing emotions from their work to
their personal life. Some respondents thus abandoned their hobbies. However, respondents
described certain personal growth judged eventually as positive, since it involved mainly the
development of their independence and responsibility and helped them to realize the priorities
of their life values. During this period respondents also experience accumulation of a large
amount of emotional changes related mainly to bringing emotions from their professional to
their private life. These emotions included sadness, fear for health of the respondent’s family
and a feeling of being older and more mature than one’s peers. Respondents also described
this period as accompanied by worries and by the need to have somebody they can share their
worries with. Mood swings, nervousness and irritability also occurred during this period.
Some respondents valued as positive the growth of their independence and responsibility and
finding out the priorities of their life values.
7. Memories about the transition from education to clinical practice
Most respondents remembered the transition period from education to clinical practice with a
smile. At the same time respondents were glad to have this life experience behind them
because it was a difficult period for them. The essays also revealed that besides the
respondents’ own feeling of security and self-confidence, the positive approach of their coworkers greatly contributed to the respondents’ subjective feeling of settling well in their
work position.
8. Recommendation from respondents to starting nurses
Respondents recommend to carefully consider one’s real possibilities and to choose a hospital
ward accordingly. According to the respondents, starting nurses shouldn’t be afraid and they
should listen to their more experienced colleagues and not underestimate their advice.
According to the respondents it is also important for starting nurses to ask questions and to
show interest not only in their work but especially in the patient. They should look for
solutions calmly and with clear head. A nurse should know her limits and not overestimate
herself, as overestimating one’s abilities can have fatal consequences. A starting nurse
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shouldn’t let herself be humiliated and shouldn’t get swept along by the routine and bad
habits at her the workplace.
DISCUSSION
Our research has shown that positive feelings our respondents experienced from transition
from education to practice were mainly connected to the vision of gaining new professional
experience and skills, to the possibility of self-fulfilment, financial independence and the
transformation of the professional role from student into a nurse.
Kramer (1974) describes a “honeymoon” stage which typically involves feelings of
enthusiasm related to finishing one’s studies and getting the status of a “professional nurse”.
However, this period doesn’t last long (Miller, 2006, p. 101-102). McMahon (2005, p. 47)
uses his own research to show that nurses coming from school to practice worry mainly about
leaving the safety which they experienced with their mentors and having to be responsible for
themselves. This was confirmed by our own research.
Our respondents stated that negative feelings experienced prior to starting their new
employment were usually connected to unknown environment, to not knowing the
interpersonal relationships at their workplace, to the increase of responsibility, low
professional confidence (caused by the lack of theoretical knowledge and lack of practical
skills), and to the bad experience they had with the workplace during their practical training.
Casey et al. (2008, p. 341-348) describes similar conclusions as he introduces the following
critical points in the transition from education to practice: a) lack of confidence in one’s skills,
problems with critical thinking and lack of clinical knowledge, b) relationships with
colleagues and mentor, c) struggle for bigger independence, d) frustration caused by the
workplace, e) organizing and setting priorities in one’s skills, f) communication with doctors.
The worst experience connected to introduction to practice mentioned by our respondents was
usually caused by demanding and unusual situations. Among the most difficult situations was
the death of a patient. Similarly to Daňková (2013, p. 79-80) we recorded feelings of sorrow,
helplessness and tiredness experienced by nurses in connection with a failed cardiopulmonary
resuscitation. Looking back at the transition period from education to practice from some time
distance the nurses participating had evaluated this period positively. However they are glad
to have this experience behind them because for them it was a very difficult and demanding
period.
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The research by Wangensteen, Johansson, Nordström (2008, p. 1877-1885) reveals that
although graduates evaluate this period as tough they appreciate it as a good experience
because of what it taught them. The initial period of clinical practice can thus be seen as an
opportunity to learn, contributing to a better professional start of the new nurse. Interpersonal
relationships, knowledge, skills and education were mentioned as other factors influencing the
initial period. Hudcová (2011, p. 104) points out in her diploma work the influence a good
work team and competent mentor have on the easy transition from education to practice.
Wangensteen, Johansson, Nordström (2008, p. 1877-1885) bring to attention the positive
effect feedback has on lowering the feeling of fear of a new nurse. In our research we saw the
following problematic fields: low level of knowledge of the mentor and the lack of feedback.
Our respondents also criticized having had multiple mentors during the initial period. Similar
findings are described in the book by Zítková et al. (2013, p. 317).
CONCLUSION
Results of our survey revealed that graduates were looking forward to the transition from
school to their first employment. The reason was anticipated independence, happiness from
working with people and the feeling of fulfilment related to getting the long-desired job.
Respondents evaluated their transition from education to practice as difficult because they had
to deal with a large amount of new information given to them over a short period of time,
with new, unknown situations and with interpersonal relationships at their workplace. Results
of the survey revealed three main factors influencing the transition from education to practice:
interpersonal relationships, knowledge, and skills and education. Appreciation and positive
feedback in the form of verbal acknowledgement or praise for well executed work were seen
as the best experience during the transition period from school to practice. On the contrary,
demanding and unusual situations, causing the feeling of being unprepared, stressed and
worried were described by respondents as the worst experience. Situations involving death of
a young patient were assessed as the most difficult ones. Essays also revealed the beginning
of clinical practice required the respondents to give up some of their hobbies. Respondents
maintained that the lack of free time and the shift work had a negative impact on their
relationships with their immediate family and friends. On the contrary, the change of their
social status was seen as positive. According to the respondents their social status increased
and people around them appreciated them more or even admired them.
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anaesthesiological and intensive care nurse. České Budějovice, 2011.Thesis. University of South Bohemia in
České Budějovice
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195-196. ISSN: 08879311.
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in Psychological Research]. 1 edition. Praha: Grada, 2006, p. 332. ISBN 80-247-1362-4.
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Nursing Scholarship,1994, vol. 26, no. 2, p. 119-127. DOI: 10.1111/j.1547-5069.1994.tb00929.x.
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WANGENSTEEN, S., JOHANSSON, I., S., NORDSTRÖM, G., The first year as a graduate nurse – an
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ZÍTKOVÁ, M., ŠPAČKOVÁ, J., MIČUDOVÁ, E., JUŘENÍKOVÁ, P., Adaptační proces – přínos či formalita,
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CONTACT AN AUTHOR
Mgr. Zdeňka Knechtová
Department of Nursing, Faculty of Medicine, Masaryk University
Kamenice 3, Brno 625 00, Czech Republic, Europe
e-mail: [email protected]
116
THE QUALITY OF CARE FOR FAMILIES OF CHILDREN WITH
CEREBRAL PALSY
Kučová Jana, Sikorová Lucie
Department of Nursing and Midwifery, Faculty of Medicine, University of Ostrava
ABSTRACT
Background: To evaluate the level of support provided to parents of children with cerebral
palsy (CP) by healthcare professionals caring for the child over the past year. Further, to
describe the factors that influence the evaluation of such support.
Methods: Quantitative approach — a survey. A shortened version of the questionnaire
Measure of Processes of Care (MPOC-20) was used. We analyzed 123 questionnaires for
parents of children with cerebral palsy aged 1–7 years. The data was evaluated in the
Microsoft Office Excel software with the use of descriptive statistics, linear regression and
analysis of variance (ANOVA).
Results: The average evaluation of health services by the respondents corresponds to the
average level of support in all five scales of the questionnaire MPOC-20. The best average
evaluation was reached in the scale Respectful and supportive care (M = 4.73), the worst in
the scale Providing general information (M = 4.19). Four items from the scale of Providing
general information (M = 3.7 and 3.8), Providing specific information about the child (M = 4)
and scale of Enabling and partnership (M = 4) were evaluated negatively. Negative evaluation
expressed by more than 50 % of respondents was noted in eight items. The evaluation results
are not influenced by age of respondents (r = -0.03 – -0.10) or education of respondents
(r = 0.06 - -0.05), age of children with cerebral palsy (r = -0.03 – -0.08), their functional
capacity or the number of medical facilities used by parents and child over the past year
(r = 0.11 – -0.08). Our research confirmed a statistically significant positive correlation
between the health condition of the child and the scale Respectful and supportive care (r =
0.21, p = 0.01).
Conclusion: To optimize the health care provided to families of children with disabilities, it
is necessary to focus on areas perceived negatively by the parents.
Key Words: parenting, cerebral palsy, services evaluation, parents´perceptions.
117
INTRODUCTION
Children with disabilities require long-term care of healthcare professionals that includes
therapeutic and nursing care as well as secondary and tertiary prevention. One of the most
important elements in the care of a child with a disability, however, is the family. Active
involvement of the family in the process of treatment and rehabilitation is vital for
development of skills of the child. This process can be significantly influenced by the
approach of healthcare professionals and subjectively perceived support provided by
professionals to a child with a disability and their family (Law et al. 2003, p. 358). The aim of
the study was to evaluate the level of support provided to parents of children with cerebral
palsy by healthcare professionals taking care of the child. Further, to describe the factors that
influenced the assessment of such support.
METHODS
Statistical Method
The research task was executed by the quantitative approach method. The level of support
provided to parents by healthcare professionals was evaluated by the shortened version of the
Measure of Processes of Care questionnaire (MPOC-20). This evaluation tool contains 20
items scored on an eight-point scale. A score of 0 indicates that the area does not apply to the
respondents. A score of 1 indicates a low level of support, a score of 7 considerable support in
the area. A higher score thus reflects a more favorable evaluation of the provided support. The
items in the MPOC-20 questionnaire are divided by areas into the scales of Enabling and
partnership (1), Providing general information (2), Providing specific information about the
child (3), Coordinated and comprehensive care (4) and Respectful and supportive care (5).
Items of particular interest are those rated an average of 4 or less (King, Rosenbaum, King
1995, p. 54). Before the start of the research, the questionnaire was translated from the
English original. Respondents evaluated approach of all the health professionals who
provided services to the child and the family in the past year.
The MPOC-20 questionnaire was complemented with personal questionnaire data. This
questionnaire included demographic characteristics (age and education of respondents, age of
children with cerebral palsy) and factors that could affect the evaluation of professional
support for parents (number of health facilities visited with the child in the past year, the
health condition of the child subjectively perceived by the parents, functional ability of the
118
child). The health condition of the child was evaluated by the parents on a five-point scale.
Functional ability of the child was evaluated using the Czech version of the Gross Motor
Function Classification System (GMFCS). The authors Palisano et al use this tool to
categorize the children by functional abilities into five classification levels with regard to the
child’s age. Children with lower functional abilities are evaluated by higher degree of
GMFCS classification (Palisano et al. 2009, p. 87, 88).
The organization of data collection
During the research, respondent sampling was applied. Sample groups were composed of
parents of children diagnosed with cerebral palsy. At the time of data collection, these
children were using the services of the participating facilities. Age of the children with
cerebral palsy was limited to 1–7 years. The research was conducted in the period between
March 2012 and April 2013 in selected healthcare or educational facilities. The distribution of
questionnaires and evaluation of functional abilities of children was ensured by the trained
managers of the participating facilities.
Evaluation of data
Data were processed using the spreadsheet software Microsoft Office Excel. For statistical
evaluation of the obtained data, we used descriptive statistics. The items of the MPOC-20
questionnaire rated 0 were excluded from the statistical evaluation. To determine the strength
of the relationship between variables, we used linear regression analysis. For statistical
evaluation of the relationship between professional support and functional abilities of the
child, we divided the respondents into three groups. We evaluated a merged category of
respondents with children with GMFCS I and II, the second group consisted of respondents
whose children had GMFCS III and the third group was a merged category of respondents
with children with GMFCS IV and V. For multiple comparisons of these data, we used
analysis of variance (ANOVA). The data were tested at a 5 % (0.05) significance level.
RESULTS
140 respondents were asked for participation in our research. 87.85 % of the addressed
parents participated in the survey, the statistical evaluation included the data of 123 parents
aged 25 to 52 years. The research sample consisted of 10 (8.13 %) fathers and 113 (91.87 %)
mothers. 23 children (18.70 %) were classified as GMFCS level I, 29 children (23.58 %) as
level II, 31 children (25.20 %) reached level III of the GMFCS classification, 11 children
119
(8.94 %) reached level IV and 29 children (23.58 %) were classified level V. The mean age of
the children was 4.4 years.
The support provided to parents as part of the healthcare services was evaluated in average
from 4.19 to 4.73 in individual scales. This corresponds to a moderate level of support in all
five scales of the MPOC-20 questionnaire. The best average evaluation was reached in the
scale of Respectful and supportive care (M = 4.73), the worst in the scale of Providing
general information (M = 4.19) (table 1).
Table 1: Descriptive statistics for scores on MPOC scales
Scale
Enabling and partnership
Providing general information
Providing specific information
Coordinated and comprehensive care
Respectful and supportive care
mean (M)
4.3
4.19
4.27
4.62
4.73
SD
1.44
1.24
1.31
1.22
1.12
Four items were evaluated negatively (table 2). The respondents pointed to the impossibility
to choose the type of information provided and the time at which the information should be
provided (M = 4). This item reflects shortcomings in the scale Enabling and partnership
between parents and service providers. Certain shortcomings were noted also in the scale
Providing specific information about the child: parents lacked written information about their
child’s progress (M = 4). As we discovered, the respondents were not provided with
information in various forms (M = 3.7). General information may be submitted in a
conversation, but also in the form of brochures or videos and it should also include advice on
how to obtain the necessary information or contacts to other parents. However, we discovered
deficiencies also in this area (M = 3.8).
In our evaluation, we also focused on negative ratings (1–4 points), expressed by more than
50 % of respondents. This was recorded in eight items. In the scale Enabling and partnership
it concerned the possibility to choose the type of received information (58 % of respondents).
In the scale General information, about 80 % of the items had such evaluation. Insufficient
was also information about the range of services offered by the organization (53 % of
respondents). Respondents also expressed a lack of opportunity for the whole family to get
information (53 % of respondents). Information provided in various forms was not available
(70 % of respondents), as well as advice on how to get information or contacts to other
parents (67 % of respondents). Greater attention in the area Providing specific information
about the child should be paid to provision of written information regarding the treatment of
120
the child (58 % of respondents) or the child’s progress (65 % of respondents). Partnership
between parents and health professionals should be a part of the Coordinated and
comprehensive care provided to families of children with cerebral palsy. From the statements
of the respondents (51 % of respondents), it can be concluded that the attitude of the
healthcare professionals has not complied with this requirement sufficiently.
Table 2: Evaluating MPOC-20
Questionnaire items sorted by mean
Have information available to you in various
forms?
Provide advice on how to get information or to
contact other parents?
Let you choose when to receive information and
the type of information you want?
Provide you with written information about your
child’s progress?
Give you information about the types of services
offered at the organization or in your community?
Provide you with written information about what
your child is doing developmentally
Make sure that at least one team member is
someone who works with you and your family
over a long period of time?
Provide opportunities for you to make decisions
about the type of service you receive?
Provide opportunities for the entire family to
obtain information?
Treat you as an equal?
Fully explain service choices to you?
Give you information about your child that is
consistent from person to person?
Tell you about the results from assessments?
Provide a caring atmosphere rather than just give
you information?
Plan together so they are all working in the same
direction?
Help you to feel competent as a parent?
Treat you as an individual?
Provide enough time to talk so you don’t feel
rushed?
Look at the needs of your ‘whole’ child?
Have information available about your child’s
developmental issue?
scale
n
median
2
107
4
mean
(M)
3.7
SD
min
max
%
1.6
1
7
70
2
108
4
3.8
1.7
1
7
67
1
117
4
4.0
1.8
1
7
58
3
120
4
4.0
1.7
1
7
65
2
112
4
4.1
1.7
1
7
53
3
119
4
4.1
1.6
1
7
58
4
115
5
4.3
1.9
1
7
44
1
118
5
4.3
1.7
1
7
45
2
108
4
4.3
1.6
1
7
53
5
1
4
117
122
118
4
5
5
4.4
4.5
4.7
1.6
1.5
1.4
1
1
1
7
7
7
51
39
39
3
5
113
118
5
5
4.7
4.7
1.7
1.6
1
1
7
7
45
38
4
117
5
4.7
1.5
1
7
41
5
5
5
116
120
121
5
5
5
4.8
4.8
4.9
1.4
1.4
1.4
1
1
1
7
7
7
36
34
31
4
2
121
116
5
5
5.0
5.0
1.5
1.6
1
1
7
7
28
37
1–4
Our survey also focused on mapping the factors that may affect the evaluation of care. In the
scale of Respectful and supportive care, a statistically significant positive correlation with the
health condition of the child was confirmed (p = 0.01). The respondents whose children were
in better health condition rated the professional support higher (r = 0.21). However, it is a low
correlation (Chráska 2007, p. 105).
121
Other variables tested, such as age and education of respondents, the number of health
facilities visited by the child in the past year, the age of the child and their functional abilities
had no significant influence on evaluation of the provided support in any scale (table 3 and
table 4).
Table 3: The influence of variables on an evaluation of support
Age of respondents
Education of respondents
Number of medical facilities
Age of child
Health condition of the child
scale 1
-0.0399
0.66
-0.0197
0.83
0.0086
0.93
-0.0828
0.36
0.0965
0.29
r
p
r
p
r
p
r
p
r
p
scale 2
-0.1092
0.23
0.0685
0.45
-0.0811
0.33
-0.0881
0.33
-0.0480
0.60
scale 3
-0.0722
0.42
-0.0313
0.73
0.0300
0.76
-0.0689
0.45
-0.0292
0.75
scale 4
-0.0743
0.41
-0.0507
0.58
0.0168
0.86
-0.0350
0.70
0.0790
0.39
scale 5
-0.0399
0.66
-0.0263
0.77
0.1138
0.25
-0.0673
0.46
0.2143
0.01
Table 4: The influence of child´s function ability on an evaluation of support
GMFCS I, II
GMFCS III
GMFCS IV, V
p-value
scale 1
M = 4.2179
M = 4.7957
M = 4.0085
0.065496
scale 2
M = 3.9029
M = 4.4690
M = 4.3597
0.069722
scale 3
M = 4.2436
M = 4.4409
M = 4.1538
0.653867
scale 4
M = 4.5994
M = 4.7984
M = 4.4936
0.584335
scale 5
M = 4.8253
M = 4.9290
M = 4.4560
0.1606
DISCUSSION
The main results of this research indicate certain deficiencies related to family-oriented care.
Average rating of individual scales corresponds to the moderate level of support with average
> 4, but the evaluation of individual items provides opportunities for improvement.
Interventions should focus not only on the area of information, but also on communication
with parents, which would improve their sense of partnership in the process of treatment,
nursing care and rehabilitation.
Another top-rated scale abroad is Respectful and supportive care, while the largest gaps
expressed by the respondents are in the scale of General information (Arnadottir, Egilson
2012, p. 66; Bjerre et al. 2004, p. 127; Dyke et al. 2005, p. 172; Granat, Lagander, Börjesson
2002, p. 462; Himuro, Kozuka, Mori 2012, p. 361; Jeglinsky, Autti-Rämö, Brogren-Carlberg
2011, p. 82; Raghavendra et al. 2007, p. 589). In this area, deficiencies were found in
information provided in various forms, advice on how to get information and written
information about the child’s progress or treatment (Saleh, Almasri 2013, online).
Conclusions of the foreign research therefore practically coincide with our results and should
lead to reflection on how to eliminate those deficiencies.
122
Although the foreign researches focus on the negative evaluation expressed by more than 33
% of respondents, we focused on the negative evaluation expressed by more than 50 % of
respondents. The reason was the large number of items that were negatively evaluated by a
third of the respondents. In our group, 90 % of the MPOC-20 questionnaire items were
evaluated negatively by more than 33 % of participants. Deficiencies in the provided care
expressed by more than 50 % of respondents were noted in 40 % of the items. Such a high
number of negative evaluation is alarming. Abroad, this evaluation is markedly higher. In
Iceland, 25 % of the items had a negative evaluation indicated by more than half of the
respondents (Arnadottir, Egilson 2012, p. 67), in Sweden and Finland it was only 10 % of the
items (Jeglinsky, Autti-Rämö, Brogren-Carlberg 2011, p. 82).
In our research, we confirmed a statistically significant relationship between the child’s health
condition and the evaluation of the Respectful and supportive care scale in MPOC-20. The
indirect link between the health condition of the child and parents’ satisfaction with health
services was pointed out by other authors as well (Law et al. 2003, p. 363). In our
investigation, negative evaluation of the health condition of the child correlated with negative
evaluation of the support of service providers. Parents, who evaluated their child’s health
negatively, may need more time for conversations. The feeling of partnership between parents
and healthcare professionals may enhance the opportunity to participate in decision-making.
The mere transmission of information by healthcare professionals may reinforce parents’
feeling of incompetence. At the same time, parents should be encouraged in their efforts to
care for a child with a disability.
The foreign scientists have also tried to describe aspects that influenced the respondents in the
evaluation of provided services. The most frequently mentioned determinant is the age of the
child. Some authors have labeled this variable as a factor influencing the evaluation of the
healthcare services (Bjerre et al. 2004, p. 127; Dyke et al. 2005, p. 172; Granat, Lagander,
Bürjesson 2002, p. 463; McConachie, Logan 2003, p. 40). However, as confirmed by the
research of other authors, this assertion is not entirely clear and requires creation of age
categories (Arnadottir, Egilson 2012, p. 67). Most of the studies compared three categories of
children aged up to 18 years. In our research, we worked with the group of respondents with
children under 7 years of age. In this evaluation, we did not confirm the correlation.
Nor other present determinants were clearly confirmed. While some authors have confirmed
the effect of functional limitations of the child on evaluation of professional support in the
123
scales Cordinated and comprehensive care and Respectful and supportive care (Saleh,
Almasri 2013, online), other authors have not confirmed this relationship in any of the five
scales (O´Neil, Palisano, Westcott 2001, p. 1420). Nor did we confirm a significant difference
in MPOC-20 evaluation in respondents whose children had different functional capabilities.
Another widely discussed factor that may be related to the evaluation of support provided by
healthcare professionals to parents of children with disabilities is the amount of received
health services. Some authors have confirmed a statistically significant difference in the
evaluation of professional support, influenced by the amount of health services required by
the child in the past year (Saleh, Almasri 2013, online). Amount of received health services,
according to other authors, also affects parental satisfaction with the provided care (Law et al.
2003, p. 363). In our research, however, we did not confirm this assertion.
CONCLUSION
Our research confirmed that the services oriented not only to the child with disabilities, but to
the whole family, require changes in the attitude of service providers. As it is clear from the
survey, the relationship between health professionals and the child’s parents should be built
up on the principles of partnership. Healthcare providers should focus on complexity of
information that, for clarity, should be provided not only verbally but also in writing.
Implementation of these expected changes would fulfil the requirements for care provided in
accordance with the philosophy of family-centered care and may have an indirect positive
effect on the development of child’s abilities.
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CONTACT AN AUTHOR
Mgr. Jana Kučová
Department of Nursing and Midwifery, Faculty of Medicine, University of Ostrava
Syllabova 19, Ostrava 703 00
Czech Republic, Europe
e-mail:
[email protected]
125
NURSING INTERVENTIONS BEFORE INVASIVE CARDIOLOGY
PROCEDURE
Líšková Miroslava
Department of Nursing, Faculty of Social Sciences and Health Care, Constantine the
Philosopher University in Nitra
ABSTRACT
Background: Nursing interventions are important for patients; they play a significant role in
life saving. Documentation of nursing activities is problematic. The objective of the study was
to evaluate dependent and independents nursing interventions performed by nurses before
invasive procedures in admitted patients with acute myocardial infarction; and to find out a
number of documented dependent and independent nursing interventions.
Methods: The data about the used and documented dependent and independent interventions
that were selected from the NIC set 4044 Cardiac Care: Acute (Bulechek, Butcher,
McCloskey Dochterman., 2008, p. 197) were obtained by direct observation of work of 13
nurses in providing nursing care to 40 patients with acute myocardial infarction before an
invasive procedure – coronarography. Statistical methods: SPSS Statistics 18 (Chi-squared
test).
Results: Out of total n=480 (100%) dependent interventions, n=132 (27.50%) interventions
were performed and documented, n=118 (24.58%) interventions were performed and not
documented, and n=230 (47.92%) were not performed. Out of total n=560 (100%)
independent interventions, n=98 (17.50%) were performed and documented, n=222 (39.64%)
were performed and not documented, and n=240 (42.86%) were not performed. The nurses
performed more independent than dependent interventions. There was statistically significant
difference (p< .05) between performed dependent and independent interventions.
Discussion: Töröková (2009) describes care for patients with acute myocardial infarction as
time consuming, particularly in an acute phase in which interventions focused on stabilization
of vital functions, medicaments administration and preparation patients for invasive procedure
are performed, as it was also in this research. Based on the research, LeRoy (2003)
recommends focusing on independent nursing interventions affecting patients’ psyche. Huber
(2009) emphasises the necessity to document interventions and monitor patients.
126
Conclusion: The research findings showed that nurses performed more independent than
dependent interventions in patients before invasive cardiology procedures, while they did not
perform all interventions form the NIC set. High frequency of interventions that were
performed and were not documented was found. Therefore, it is important to make the
nursing documentation more effective, particularly via information and communication
technologies.
Key Words: nursing interventions, invasive cardiology procedure, myocardial infarction,
nurse, documentation of activities
INTRODUCTION
The issues of cardiovascular diseases as civilization diseases have been discussed for several
decades in all developed countries where ischaemic heart disease and its critical consequence
myocardial infarction have had an increasing tendency. The Slovak Republic is one of the
countries with a high cardiovascular risk (Klener, 2011). Suffering from a cardiovascular
disease can be reduced through early diagnosis, suitable care management, rehabilitation and
prevention. Coronarography is an invasive cardiology procedure; an examination affects the
patient’s body, is connected with some risks, and is carried out during hospitalization.
Coronarography as an X-ray method used for imaging the anatomy of coronary arteries and
their congenital anomalies brings the information about occurrence, extent and seriousness of
arteriosclerotic changes (Huber, 2009). It images collateral circulation and allows diagnosis of
coronary arteries spasms. Selective coronarography has several indications: effort (stable) AP,
variant AP, unstable AP, acute myocardial infarction, status post myocardial infarction, and
silent myocardial ischaemia. Coronarography is also indicated in patients with heart failure,
arrhythmias of unknown origin, and in patients with valvular impairment before planned
surgical treatment (Kolář, 2009). Coronarographic findings are of essential significance in
decision making about treatment of patients. Based on the coronarography findings along
with the clinical findings and the results of non-invasive tests, it is decided upon the
indication of surgical treatment, revascularization by the method of a balloon coronary
angioplasty, or conservative methods (Kotíková, 2010). Percutaneous Coronary Intervention
(PCI) is a label for catheterization procedures resulting in improved blood flow through
narrowed coronary arteries. Dilatation of a coronary artery described as Percutaneous
Transluminal Coronary Angioplasty (PTCA) with the use of a special balloon was performed
for the first time by Andreas Grüntzig in 1977. In the present, the balloon dilatation of
127
coronary artery is almost always complemented or replaced by coronary stent implantation
(Assherman, 2004).
Nursing interventions in providing nursing care, which includes identifying the needs, nursing
documentation and evaluation of outcomes of nursing care, play an important role because
high-quality nursing care maximises the final therapeutic effects, which finally positively
affects the quality of life of patients after myocardial infarction (Vörösová, 2013). Bulechek,
Butcher, McCloskey Dochterman (2008, p. 3) state that “the Nursing Interventions
Classification (NIC) is a comprehensive standardized classification of interventions that
nurses perform”. It is used in clinical documentation, effectiveness research, and
communication in providing care. In the use of NIC in providing care, the cooperation of all
nurses in all specialties from critical care to outpatient care, to long-term care is necessary.
NIC interventions include physiological and psychological spheres, and treatment using
dependent and independent activities that are carried out by nurses in direct and indirect care
on behalf of patients. Each intervention includes a label, a definition and activities, while a
labels and definitions cannot be changed when used. Nursing interventions are important for
patients; they play a significant role in life saving. Nurses perform dependent, independent
and collaborative interventions (Berman, Snyder, 2012). The objective of the study was to
evaluate dependent and independent nursing interventions performed by nurses before
invasive procedures in patients with acute myocardial infarction. In care for patients with
acute myocardial infarction, one of the nurses’ roles is affecting the patients’ psyche (Huber,
2009; Kotíková, 2010; LeRoy et al. 2003). Performance of more independent than dependent
nursing interventions in providing nursing care in patients with acute myocardial infarction
before invasive procedure was expected. The problem in clinical practice is documentation of
all nursing activities. Another objective was to find out the number of documented dependent
and independent nursing interventions.
METHODS
The data about the used dependent and independent interventions that were selected from the
NIC set (Bulechek, Butcher, McCloskey Dochterman., 2008,) were obtained by direct
observation of work of 13 nurses in providing nursing care to 40 patients with acute
myocardial infarction before an invasive procedure. The interventions from the NIC set 4044
Cardiac Care: Acute were used. The interventions were divided to 12 dependent (admit the
patient; apply IV cannula; take vital signs; obtain 12-lead ECG; administer oxygen therapy;
128
apply permanent catheter in a woman, or assist in applying permanent catheter in a man;
monitor the patient continuously; monitor fluid balance; administer IV therapy; administer
medication per os; take blood samples for lab tests) and 14 independent (documentation;
monitor consciousness; obtain nursing history; calm the patient and next of kin; educate the
patient about invasive procedure; assess chest pain; position the patient; prepare arterial
access before procedure; care about IV cannula; administer liquids per os; monitor lab values;
provide hygienic care to the patient; provide quiet and peaceful environment; auscultate heart
and lungs). In accordance with research, the sets of interventions were divided into three
categories: performed and documented interventions; performed and not documented
interventions; and not performed interventions. The work of nurses in care for patients before
coronarography was observed, and the information about performing and documenting the
interventions into the documentation by nurses in the Cardiocenter in Nitra was recorded.
Documentation of the interventions in the patients’ records was double-checked at the end of
the shifts. The exclusion criteria for sampling were: a nurse with practice at cardiology shorter
than one year, and a patient transferred from another healthcare facility. Observations were
carried out from January to March 2013. SPSS Statitics 18 was used for statistical data
processing using the Chi-squared test, as recommended by Sollár, Ritomský (2002).
RESULTS
In the set of dependent interventions in the category of the performed and documented
interventions, the highest frequency was found in the interventions: admit the patient n=39,
and take vital signs n=37; there was no frequency in the interventions: apply permanent
catheter in a woman, monitor fluid balance, and administer medication per os. In the category
of performed and not documented interventions, the highest frequency was found in the
interventions: administer oxygen therapy n=38, and monitor the patient continuously n=23.
Never performed interventions were: apply permanent catheter in a woman n=23; and a high
frequency in not performed interventions was in: apply IV cannula. The total number of the
performed dependent interventions was n=250. The dependent interventions that were
always performed included: admit the patient; monitor vital signs; administer oxygen therapy;
monitor the patient continuously; and take blood samples for lab tests.
Other quantitative data about the used dependent nursing interventions before invasive
procedure are shown in the Table 1.
129
Table 1 Dependent interventions before invasive procedure
Intervention
Performed and
documented
n
%
39
97.50
2
5.00
37
92.50
4
10.00
2
5.00
0
0.00
2
5.00
Admit the patient
Apply IV cannula
Take vital signs
Obtain 12-lead ECG
Administer oxygen therapy
Apply permanent catheter in a woman
Assist in applying permanent catheter in
a man
Monitor the patient continuously
Monitor fluid balance
Administer IV therapy
Administer medication per os
Take blood samples for lab tests
17
0
2
0
27
Performed and not
documented
n
%
1
2.50
0
0.00
3
7.50
17
42.50
38
95.00
0
0.00
3
7.50
42.50
0.00
5.00
0.00
67.50
23
7
8
5
13
Not performed
57.50
17.50
20.00
12.50
32.50
n
0
38
0
19
0
40
35
%
0.00
95.00
0.00
47.50
0.00
100.00
87.50
0
33
30
35
0
0.00
82.50
75.00
87.50
0.00
In the set of the independent interventions in the category of the performed and documented
interventions, the highest frequency was found in the interventions: documentation n=37, and
obtain nursing history n=32. In the category performed and not documented interventions, the
highest frequency was found in the interventions: position the patient n=38; auscultate heart
and lungs n=33; and monitor consciousness, and care about IV cannula n=32. Never
performed intervention was: provide hygienic care to the patient n=40. In the category of the
interventions that were not performed, the high frequency was found in: calm the patient and
next of kin n=38; and administer liquids per os n=37. The total number of the performed
independent interventions was n=320.
Table 2 Independent interventions before invasive procedure
Intervention
Documentation
Monitor consciousness
Obtain nursing history
Calm the patient and next of kin
Educate the patient about invasive
procedure
Assess chest pain
Position the patient
Prepare arterial access before
procedure
Care about IV cannula
Administer liquids per os
Monitor lab values
Provide hygienic care to the patient
Provide quiet and peaceful
environment
Auscultate heart and lungs
Performed and
documented
n
%
37
92.50
0
0.00
32
80.00
0
0.00
19
47.50
Performed and not
documented
n
%
3
7.50
32
80.00
7
17.50
2
5.00
13
32.50
Not performed
n
0
8
1
38
8
%
0.00
20.00
2.50
95.00
20.00
3
0
2
7.50
0.00
5.00
8
38
23
20.00
95.00
57.50
29
2
15
72.50
5.00
37.50
5
0
0
32
3
5
0
23
80.00
7.50
12.50
0.00
57.50
3
37
35
0
0
12.50
0.00
0.00
0.00
0.00
40
17
7.50
92.50
87.50
100.00
42.50
0
0.00
33
82.50
7
17.50
130
The independent interventions that were always performed included documentation. Other
quantitative data about the used independent nursing interventions before invasive procedure
are shown in the Table 2.
Out of total n=480 (100%) dependent interventions, n=132 (27.5%) were performed and
documented, n=118 (24.58%) were performed and not documented, and n=230 (47.92%)
were not performed. Out of total n=560 (100%) independent interventions, n=98 (17.50%)
were performed and documented, n=222 (39.64%) were performed and not documented, and
n=240 (42.86%) were not performed. There were n=570 performed interventions including
n=250 dependent and n=320 independent interventions before invasive procedure. There
were n=470 interventions from the NIC set 4044 Cardiac Care: Acute that were not
performed at all. The nurses performed more independent than dependent interventions. Other
quantitative data are shown in the Table 3.
Table 3 Comparison of dependent and independent interventions before invasive procedure
Interventions
Performed and documented
Performed and not documented
Not performed
Total
Dependent
interventions
n
132
118
230
480
%
27.50
24.58
47.92
100.00
Independent
interventions
n
98
222
240
560
%
17.50
39.64
42.86
100.00
The obtained data about the independent and dependent interventions before invasive
procedure were processed by descriptive statistics as well as by the Chi-squared test to find
the statistical significance. The values of the Chi-squared test (χ2(2) =8.596; p= .003) confirm
the statistically significant difference (p< .05).
DISCUSSION
The aim of using the standard nursing terminology is accurate definition and description of
the activities that nurses perform related to specific needs of patients to achieve specific goals
(Škrla, Škrlová, 2003). Development of the standardized nursing terminology is significant in
promotion of professional responsibility and independence of nursing interventions and
promotion of communication between the members of the multidisciplinary teams (Vörösová,
2007). The Nursing Interventions Classification (NIC) is the basis for providing evidencebased care. Berman, Snyder (2012), and Vörösová (2013) describe the efforts to make the
nursing profession autonomous that are reflected in greater independence of nurses in their
131
work as well as in care for patients in critical situations. The research results proved the
statistically significant difference in the number of performed independent nursing
interventions in care for patients with acute myocardial infarction before invasive cardiology
procedure compared to the dependent interventions.
Töröková (2009) describes the treatment of patients with acute myocardial infarction as time
consuming, particularly in an acute phase when the interventions focused on stabilization of
vital signs, administration of medicaments and preparation of patients for an invasive
procedure are performed; as this research also shows.
Kolář (2009) describes the launch of intensive care after admission of patients with acute
myocardial infarction to a coronary care unit in several steps that include calming the patient,
pain relief, initiating IV access, taking blood samples for biochemical tests, initiating ECG
and BP monitoring, and oxygen therapy. Both dependent and independent nursing
interventions are included. Huber (2009) presents calming the patient and next of kin as a
significant factor related to success, therapy-sensitive outcomes and patient’s safety; in the
findings it was presented only in two cases. Both physicians and nurses are involved in pain
management; it is important to monitor and assess pain. Lower frequency was found in the
intervention pain assessment; it was performed in ten cases. An explanation might be looked
for in persistent concentration on the patients’ somatic problems and the interventions used to
meet biological needs. LeRoy (2003) recommends focusing on the independent nursing
interventions affecting patients’ psyche.
Mechírová (2008) suggests general measurements for acute myocardial infarction that include
obtain nursing history, calming and explaining the situation to the patient, rapid examination,
positioning of the patient, initiating IV access, and oxygen therapy. The research findings
proved the measurements. The most often performed independent interventions in research
were: documentation, educate the patient about invasive procedure, obtain history, position
the patient, and care for IV cannula. LeRoy (2003) emphasizes the need of education before
every invasive procedure in patients in all age groups taking age into consideration. The most
often performed dependent interventions were: admit the patient, monitor vital signs, provide
oxygen therapy, monitor the patient continuously, and take blood samples for lab tests.
Huber (2009) and Bulechek, Butcher, McCloskey Dochterman (2008) emphasize the need of
documentation of the interventions and monitoring the patient. The most often documented
independent interventions before invasive procedure were: documentation, obtain nursing
132
history, and educate the patient about invasive procedure. The most often documented
dependent interventions before invasive procedure were: admit the patient, and monitor vital
signs. Rather high frequency of the interventions that were performed but were not
documented was also found. Similar findings are stated by Huber (2009), Vörösová a kol.
(2007), and Berman, Snyder (2012).
The interventions that were not performed included: provide hygienic care to the patient, and
apply permanent catheter in a woman. The interventions with a high level of nonimplementation included: apply IV cannula as most of the patients were transported by an
ambulance and IV cannula had been applied by the crew, as Zadák, Havel a kol. (2007) state;
apply permanent catheter in a woman as there was no need to perform this intervention; calm
the patient and next of kin, as mentioned above; and administer liquids per os.
The research limitations may be: the size of the samples of nurses and patients, and the use of
the classification system – selection and division of the interventions. The findings might
have been affected by a certain level of subjective assessment of the interventions by the
observer.
CONCLUSION
The research findings showed that nurses performed more independent than dependent
interventions in patients before invasive cardiology procedure; they did not perform all
interventions from the classification system NIC. The most often performed independent
interventions were: obtain nursing history, educate the patient about invasive procedure, and
auscultate heart and lungs. The most often performed dependent interventions were: monitor
vital signs, administer oxygen therapy, monitor the patient continuously, and take blood
samples for lab tests. High frequency of the interventions that were performed but were not
documented was found. Therefore, it is important to make documentation more effective
using the information and communication technologies. It was also found that biological
needs were treated more often than mental needs; there is a space for pre-gradual as well as
lifelong nursing education.
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The paper is the outcome of the CGA project VIII/13/2012 Psychosocial Needs of the Ill in
Nursing
CONTACT AN AUTHOR
PhDr. Miroslava Líšková, PhD.
Katedra ošetrovateľstva, FSVaZ
UKF v Nitre
Kraskova 1, Nitra 949 74 Nitra, Slovak Republic
e-mail: [email protected]
134
IDENTIFICATION OF NEGATIVE EXPERIENCE AND RISK
FACTORS POST-TRAUMATIC STRESS DISORDER OF WOMEN IN
RELATION TO CHILDBIRTH
Mazúchová Lucia, Kelčíková Simona, Paráková Dominika
Department of Midwifery, Jessenius Faculty of Medicine in Martin, Comenius University
ABSTRACT
Beckground: Childbirth could be exceptionally stressful event, resembling experienced birth
trauma, meeting the diagnostic criteria of post-traumatic stress disorder (PTSD). The aim of
the thesis was to analyze negative experience of women from childbirth to find out the
incidence of PTSD symptoms.
Methods: The questionnaire- quantitative explorative method has been used and
supplemented with the scale focused on finding PTSD symptoms (Mrowetz et al., 2011). 225
women respondents have participated in this study (age 29,64 ± 7,34 years) and the
categorized criterion was a negative experience from childbirth. We have used a descriptive
statistic to process gathered data from a questionnaire.
Results: Negative experience of women from childbirth was mostly related to a complicated
childbirth (25,37 %), to bad personnel attitude (18,56 %), to severe pain (13,98 %), to
insufficient awareness (11,94 %), to lack of privacy (10,67 %) and loss of dignity (10,67 %).
The PTSD risk in relation to the parturition has been proved overall by 3,56% of women. The
most frequent PTSD symptoms after the birth were fear from repeating the negative childbirth
(16,93 %), not resembling a chilbirth (11,36 %) and a feeling of panic while recalling the
childbirth (10,91 %). The Professional attention (psychologist, psychiatrist) has been sought
by 1, 95 % of women.
Conclusion: Our results are comparable with the results of studies realized abroad. They state
the prevalence of PTSD after the childbirth by 1,5 – 6 % of women (Beck, 2004; Adewuya et
al., 2006; Alder et al., 2006). The results pointed out facts that negative experience from
childbirth and birth trauma of women is related to the influence of negative factors
(complicated childbirth, pain, bad personell attitude, insufficient awareness, loss of dignity...)
that could be minimized and prevented by a professional, individual, and empathetic attitude
of a midwifery.
135
Key Words: childbirth, negative experience, birth trauma, post-traumatic stress disorder,
midwifery
INTRODUCTION
Childbirth is a unique event when woman is exceptionally sensitive to everything that is
happening around her and it could have positive, but also negative impact on psychical,
physical as well as social area of mother and child. If a woman is not able to handle a negative
childbirth experience, it could lead to post-traumatic stress disorder (PTSD). PTSD is a longtime maladaptive (inadequate) reaction on shatterring traumatic event that exceeds common
human experience and is represented by set of pieces of non-anticipation and nonmanageability (Gurková et al., p. 147, Baštecká, Golman, 2001 p. 275 ). If the childbirth is
cause of PTSD, we speak about birth trauma (Faithová, 2012, p. 1).
Psychical experiencing of pregnancy like experiencing of childbirth is distinctively individual
and is influenced by many factors arising from a personality of expectant mother as well as by
factors from external environment. Childbirth in the present days is full of stressful influences
on woman and foetus and this is caused by unfamiliar and unsettled environment of a birth
hall, by sight on the medical instruments, by noise, by impersonal attitude of hospital
attendants or by sharp lighting (Eliášová, 2008, p. 94). It could be also influenced by activity
of expectant mother, by self-sufficiency, by the ability to accept help, relation to own
feminity, ability to assimilate, self-confidence, relation to a child, religious conviction, and
amount of cooperation between body and soul. Physical progress of childbirth and psychical
condition of expectant mother are in connection and mutually influence each other. Women
with PTSD feel anxiety, sorrow, pain, hate, regret, anger, they loose the feeling of safety and
security, some of them perceive childbirth as a rape, and they often think they are
experiencing postpartum depression. They have a feeling that after a childbirth something has
happened to them, they are not able to dismiss it from the mind (Mrowetz, 2011, p. 55,
Vágnerová, 2012, p. 52).
The aim of the study was to find out, analyze and evaluate negative experience of women and
occurence of post-traumatic stress disorder symptoms in relation to childbirth.
METHODS
The questionnaire- quantitative explorative method has been used and supplemented with the
scale focused on finding PTSD symptoms (Mrowetz et al., 2011). 225 women respondents
136
have participated in this study (age 29,64 ± 7,34 years) and the categorized criterion was
a negative experience from childbirth. Questionnaires have been at first verified by 10 women
respondets participating in the pilot study. After a few corrections (formulation of questions),
we have put final version of questionnaires together. The study was realized from December
2013 to January 2014. Administration of a questionnaire has been performed personally or via
e-mail. Women respondents have been addressed via internet portal where we have placed
web address of our questionnaire. We have used a descriptive statistic to process gathered
data from a questionnaire.
In the scale focused on finding PTSD symptoms, we have counted a number of symptoms that
have been marked by the respondents. The number of 7 to 9 symptoms has been regarded as
a light form of PTSD, a number of 10 to 12 symptoms have represented medium-serious form
of PTSD and more than 12 symptoms have been characterized as serious form of PTSD after
the childbirth.
RESULTS
Our goal was to obtain 250 questionnaires. We have finally obtained 225 that has represented
a recoverability of 90%. The majority of respondents had university degree (60,89 %) and
high school education (36,40 %). The average number of childbirths of all respondents was
1,44. The period from parturition related to negative experience was in the range from 0,1 to
10 years, in average 2,74 years. We have found that trouble-free pregnancy (it was
a subjective evaluation) was mentioned by 53,38 % respondents. Trouble-free pregnancy has
been divided into pregnancy with minor problems (37,33 %), and with major problems (6,67
%) Within the birth at term, a child was born to 54,67 % of respondents, prematurely to 11,11
% of respondents and after the birth term, 34,22 % of respondents have born a child.
Table 1: Connection of negative experience with childbirth
Complicated
childbirth
n
%
138
25,37
Lack of privacy and
dignity
n
%
58
10,67
Bad attitude of
Severe pain
Fear of a baby
Childbirth of
personnel
a dead baby
n
%
n
%
n
%
n
%
101
18,56
76
13,98
56
10,30
3
0,55
Lack of information
Loss of self-control
Total
and explanations
feeling
n
%
n
%
n
%
65
11,94
47
8,63
544
100
137
There were several options of the answers, in total 544 options have been indicated. The most
frequent reason of negative experience with the childbirth was a complicated childbrith (25,3
%), bad attitude of personnel (18,56 %) and severe pain (13,98 %).
Table 2. PTSD symptoms
PTSD symptoms
%
Order
occurence
Event that you have experienced is interpreted as extreme stress
7,35
5.
Whenever you think of this event, you feel panic
You are afraid that this event could re-occur
You fear when thinking of this situation
You do not want to remember this event
You get frightened quickly and rapidly
You try to avoid feelings related to this event
Certain images and sounds are coerced to you
You loose interest in important activities
You have difficulties with concentration
10,91
16,93
7,13
11,36
0,45
7,13
4,23
0,45
1,56
4.
1.
6.
3.
12.
6.
8.
12.
11.
Thoughts on the event are disturbing my learning
You avoid social life
You suffer from guilty feelings
Undesirable thoughts are coerced to you
You have bad dreams
Your sleep is disrupted
0,45
1,56
6,46
3,34
2,90
2,23
12.
11.
7.
9.
10.
9
None of these symtoms are related to me
15,56
2.
In this item, we have used a scale in order to find out PTSD symptoms after the childbirth.
The most frequent symptoms that refer to the risk of PTSD in our group of respondents were
these ones: fear of re-occurence of this negative event (16,93 %), avoidance of resembling
this event (11,36 %) and a feeling of panic while recalling this event (10,91 %).
Table 3. Forms of PTSD symptoms
Without
significant
symptoms
n
%
217
96,44
Light form
Medium-serious
form
Serious form
Total
n
6
n
2
n
0
n
225
%
2,67
%
0,89
%
0,00
%
100
PTSD risk has been identified in total by 8 women (3,56 %). 6 women have proved to face
light form of PTSD (2,67 %) and 2 women (0,89 %) have faced risk of medium serious form
of PTSD.
DISCUSSION
Negative experience of women from childbirth is insufficiently discussed, but this is a real
and serious problem. Consequences of negative women´ experiences in relation to childbirth
138
could influence their daily lives, they have influence on their psychical, physical and social
area, their partners and other family members (Faithová, 2012, p.1).
In our study focused on the negative experience of women from childbirth, and by way of
certain scale, we have been investigating the occurence of PTSD symptoms after the
childbirth (table 1.). In the group of our women respondents, the most frequent symptoms that
indicate PTSD risk were as follows: fear from re-occurence of this negative event (16,93 %),
not resembling this event (11,36 %) and a feeling of panic while resembling this event (10,91
%). According to specialist as well (Baštecká, Golman,2001, p. 276, Hašto, Vojtová, 2012, p.
14), the main elements of traumatic reaction are regressed images about this event, avoidance
of places and situations reminding this event, and excessive sensitivity. 36,44 % of
respondents in our study has stated that since the 1st day after the childbirth, they were
suffering from repeatedly regressing of momeries on childbirth that according to Vodáčková
(2012, p. 236), decreases the quality of life and at the same time it represents one of the
symptoms of childbirth trauma. The risk of post-traumatic stress disorder has been proved by
3,56 % respondents in our study (table 2.). Our results are comparable with the results of
studies realized abroad. They state the prevalence of PTSD after the childbirth by 1,5 – 6 % of
women (Beck, 2004, p. 216; Adewuya et al., 2006, p. 287; Alder et al., 2006, p. 107). Based
on our study, it results that 2,67 % respondents have experienced risk of light PTSD form.
The risk of medium serious form of PTSD has been detected by 0,89 % respondents. Many
women, thanks to their psychical resistance and support of their relatives, are able to handle to
a certain extent exceptionally traumatic experience from childbirth. Others are not so lucky
and cope with these problems in the long term and in the great extent. The symptoms of birth
trauma are individual for every woman and are influenced by many factors. If a woman is
able to handle negative childbirth experience without a significant presence of above
mentioned symptoms, birth trauma is not indicated. However, it does not mean it is not
necessary to deal with the problem why a woman perceives her childbirth negatively or what
consequences it has got on her psychical experience, on the perception of herself or on her
relations.
PTSD after the childbirth could also disrupt relationship between mother and child, it could
have long-term impact on psychical and physical development of a child, on a quality of
parenthood and partnership after the childbirth (Beck 2004, p. 220, Geisel, 2004, p. 14,
Kodyšová, 2014, p. 26, Ayers, 2006, p. 389) 17,78 % respondents in our study have stated
139
that negative experience from childbirth has also influenced their relationship with a baby.
Due to the negative experience from childbirth, 18,22 % respondents have refused to have
another baby. Just for a certain period of time, it has influenced 30,67 % respondents.
According to Mrowetz as well (2013, p. 62), women with the negative childbirth experience
have problems with relation to their baby and partner and try to avoid another pregnancy.
PTSD after the childbirth is often interchanged with postpartum depression. These women do
not need antidepressants that are prescribed by a doctor for wrongly diagnosed postpartum
depression. They mainly need conversation, support from another person that could be also
midwifery. In our study, we have also surveyed which strategies and supporting people have
helped women with coping with the negative experience after childbirth. Some respondents
(4,20 %) have stated they have refused to communicate with anybody and basically refuse
any support. On the contrary, 6,70 % respondents needed such support, but nobody has
provided it. Support from the side of midwife has been stated by 3,91 % respondents. Doctorgynaecologist has provided support to 3,36 % respondents. Conversation and support from the
side of husband/partner has been stated as the most helful by the highest amount of
respondents (28,77 %), conversation with women friends ( 24,02 %), support from the side of
a family (26,81 %). Professional help in the form of visiting psychologist or psychiatrist has
been sought by 1,95 % respondents. With the help of medication, the negative childbirth
experience has been coped with 0,27 % respondents. Michalovičová (2006, p. 112) states that
the 1st step is to visit a psychologist. PTSD is very good and promptly psychotherapeuticly
cured. Cognitive-behavioral therapy is recommended as it does not burden mother and child
and has got positive influence on the whole family and mainly on another pregnancy.
Pharmacotherapy is suitable for more serious psychopathology where a significant decrease
of life quality could be faced.
In our study, we have been surveying the reasons of negative experience of women after the
childbirth (table 3.). The most common reason of negative experience in our group of
respondents was a complicated childbirth (25,37 %). Complicated parturition has been
regarded by the respondents as follows: childbirth wih the help of forceps or vacuumextractor, acute section, induced childbirth, too many unnecessary medical interventions,
epiziotomy and consequent stitching that has caused impossibility to move and sit as well as
long-term pain. Our findings are in accordance with the results of other studies where
extemporary caesarean, childbirth induction, instrumental vaginal childbirth, and epiziotomy
have been proved as the main predictors of post-traumatic stress symptoms after the childbirth
140
(Maggioni et al., 2006, p. 86; Tanya, 2008, p. 24; Alder et al., 2006, p. 109 ). As also stated
by Mrowetz et al. (2011, s. 56) PTSD is most frequently arised by routine medical
interventions, such as provocation or acceleration of childbirth, epiziotomy, childbirth where
forceps or vacuum- extractor are used, or acute caesarean. Odent (2011, p. 120, 121) states
that it is essential to go an extra mile for reduction of intesive medical assistance in order to
avoid any unnecessary risk towards mother and child. The majority of doctors repeatedly
reminds „risk factor“ by which they express a generally accepted interest in the safety of
mother and child in order to excuse mass use of medicaments and discredit other possibilities,
where a woman could easily move after the childbirth, be in the vertical positions in which
certain complications are not expressed and other medical interventions are not necessary. It
is not unequivocal if an approach that includes a widespread use of sedatives, application of
artificial hormones in order to accelerate childbirth, epidural and other types of anaesthesia,
using pincers and daily application of cesarean, decreases risk factors because many of these
medical interventions bring new risks. The other group of respondents (18,56 %) has stated
that their negative experience was related to the attitude of medical personnel. We were
inquiring our respondents about the attitude of midwives and doctors during the childbirth.
The attitude of midwives has been positively (as good, empathetic, professional) evaluated by
38,00 % respondents and negatively by 62 % respondents. It has been concerned
nonprofessional attitude (5,75 %), master behaviour (12,50 %), unfriendly behaviour (5,00
%), some women have experienced unappropriate and undignified comments (11,00 %),
ignoring attitude (7,00 %) impersonal attitude (14,50 %) and other evaluation (6,25 %) that
has been mostly described by respondents that they even do not remember midwives as there
were too many of them and changing each other and that some of them have had threatening
attitude. A midwifery should assist mainly to an expectant mother, but in our maternity
hospitals, it is more frequently an assistant of a doctor. The role of a midwifery is to secure
a feeling of safety for women during the childbirth, to make privacy for them, to secure
sufficient awareness of all procedures and examinations that are recommended during
childbirth and to provide emotional support by individual and empathetic attitude and as well
as to avoid negative factors that could arose negative experience from childbirth and could
lead to birth trauma (Gaskin, 2010, p. 429). The attitude of doctors has been positively (as
good, empathetic, professional) evaluated by 47,41 % respondents and negatively by 52,59 %
respondents. It has concerned nonprofessional attitude (6,44 %), master behaviour (12,38 %),
unfriendly behaviour (3,35 %), unappropriate and undignified comments during childbirth
141
(6,44 %), ignoring attitude (5,41 %), impersonal attitude (12,38 %) and other evaluation (6,19
%), that has been mostly described by various reproofs from the side of doctors, derision,
manipular and threatening attitude, or no communication. We can state that the negative
attitude has been outbalanced in the evaluation of doctors and midwives and according to
some women, this has also been a cause of negative experience from childbirth and
consequently a risk of PTSD. The attitude of medical personnel during childbirth has
a significant influence on the psychical status of an expectant mother. According to
Balaskasová (2010, p. 193) those who take care of a woman during childbirth, should
consider themselves as her guests which role is to help her all the time. Mrowetz et al. (2011,
p. 61) states that sorrow of a mother after childbirth is not a consequence of a hormone
imbalance or social problems, as many of the medical personnel suppose so. It is a direct
consequence of careless organization of childbirth in the ordinary hospital where the priority
is represented by routine programmed medical attitude and child separation from mother
instead of satisfying expectant mother´s needs. According to Vodáčková (2012, p. 234 ) there
is no excuse if a starter of birth trauma is initiated by medical personnel. Mrowetz et al.
(2011, p. 101) recommends hospital attendants psychosocial preparation and regular
supervision. Supervision is a prevention from burnout syndrome, it creates assumptions and
conditions for professional development, as well as it could function as a mean for improving
work with expectant mothers. In case a hospital attendant should really support an expectant
mother, at first safety needs must be secured for her. However this should never have impact
on psychosocial needs of women, as it is frequently happening these days. According to
Vodáčková as well (2012, p. 237) maximal respect towards psychical needs of an expectant
mother should be taken, she should feel safely, give birth in the pleasant environment, she
should not be handed over to somebody who makes decision about her, but to somebody who
is asking what exactly she wishes. Negative experience from childbirth stated by 13,98 %
respondents was related to serious pain. Women have different pain thresholds and so it is
necessary to take individial attitude to every woman. In the past, we used to talk about the
birth pangs that has its own significance. It helped mother to find a suitable position while
delivering a baby and as well as to correctly cooperate with the baby. Not understanding of
a meaning of birth pangs often leads to fear of an expectant mother. Pain becomes
a pathology and it gets under the competence of a doctor that tries to cure it, release it or
eliminate it straight away. By this, its productive force is suppressed (Mrowetz et al., 2011, p.
10). Negative emotions that have control over a woman even before some pain occurs have
142
specific influence on the childbirth progress and pain itself. Expectant mothers coming to
a birth hall are worried, feared and feel anxiety from an unknown environment. As a final
consequence, these psychical factors influence that an expectant mother perceives subliminal
impulses as intensive pain (Eliášová, 2008, p. 65).
Other negative experience of women with childbirth were related to lack of information and
explanations during childbirth (11,94 %), to lack of privacy (10,67 %), to excessive fear
about a child (10,35 % ), to a feeling of self-control (8,63 %), to a childbirth of a dead baby
or death of a baby after the childbirth (0,55 % ). According to Beck as well (2004, p. 217),
the origin of birth trauma is mainly subjected by highly painful childbirth, childbirth
induction, low pain threshold, feelings of loosing control, or insufficient communication from
the side of medical personnel. Odent emphasizes (2011, p. 70) that privacy, intimacy,
semidarkness, silence, freedom to move and make some noise, give birth in whatever
position, as well as presence of sensitive midwives that do not behave as observers only, have
significant influence on spontaneous birth progress.
CONCLUSION
For the practice of midwives, it is necessary to get familiar with problems of negative women
experience and postpartum trauma, that has been also an intention of our study. Midwifery
should know and participate in prevention and elimination of all inconvenient factors that
could cause negative experience of women and so actively participate in the prevention of
birth trauma. From the side of midwives, it is necessary not to negatively interfere into
childbirth process, but on the contrary not only express professional support, but also show
interest in an expectant mother by empathetic, dignified and individual attitude as well as to
create the most suitable conditions for the childbirth itself. In case of negative experience of
women, it is necessary that midwifery realizes it in due time and consequently provides them
appropriate help and support. At the same time, it is essential to increase the awareness of
PTSD and raise efforts in the reseach of this area.
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Obstetrics & Gynecology. 2006, vol. 27, no. 2, p. 107-112. ISSN 0167-482X.
AYERS S, EAGLE A, WARING H. The effects of parturition related PTSD on
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Univerzita Palackého v Olomouci, 2012. 186 p. ISBN 978-80-244-2944-1.
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sociální opory při porodu. Psychosom. 2014, vol. 12, no. 1, p. 25-34. ISSN 1214-6102.
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two-wave longitudinal study. Journal of Psychosomatic Obstetrics & Gynecology. 2006, vol. 27, no. 2, p.
81–90. ISSN 0167-482X.
MICHALOVIČOVÁ S. 2006. Popôrodné a pooperačné psychiatrické komplikácie. Slovenská gynekológia
a pôrodníctvo. 2006, vol. 2006, no. 13, p. 108 – 115. ISSN 1335-0862.
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CONTACT AN AUTHOR
Mgr. Lucia Mazúchová, PhD.
Department of Midwifery, Jessenius Faculty of Medicine, Comenius University
Malá Hora 5 , 036 01 Martin, Slovakia, Europe
e-mail: [email protected]
144
THE RISK OF FALLING IN OPHTHALMICAL NURSING
Mesárošová Jozefína
Department of Nursing, Faculty of Social Sciences and Health, University of Constantine the
Philosopher in Nitra
ABSTRACT
Background: To evaluate the risk of falls in the hospitalized ophthalmic patient due to the
age of the patient and in relation to the medical diagnosis.
Methods: Quantitative research method - observation - measurement using a screening test to
determine the risk of falls, functional Gait assessment test to determine the balance and fall
prevention in the survey sample of 90 respondents in the age range from 45 years up to
longevity with selected medical diagnoses. Statistical processing method, the use of inductive
statistics of Chi-squared test and T-test.
Results: The level of significance of the chi-squared test for both tests p = 0.001 and p =
0.001, is less than 0.05 – and it is statistically significant, between the observed groups (45-74
years and 75-longevity) there is a statistically significant difference, it implies that the risk of
falling will increase with the age of the patient. The levels of significance of the T-test for
cataracts and Age-Related Macular Degeneration (ARMD) and p = 0.025 for cataract and
Diabetic Retinopathy (DR) p = 0.004 are less than 0.05, and are statistically significant. The
level of significance of the T-test for ARMD and DR p = 0.467 is significantly higher than
0.05 is not statistically significant. The risk of falling is higher among respondents with a
medical diagnosis of cataract than the medical diagnosis of Age-related Macular Degeneration
and Diabetic Retinopathy.
Discussion: The results are consistent with the opinion of Frantová, Beťková (2010) that the
Gait functional test and screening test to determine the risk of falling belong to the tests which
are applicable in practice.
Conclusion: Most falls can be prevented by a high quality and targeted prevention. By
creating, compliance, documenting the procedures which lead to the assessment of the risk of
falling and reduce the number of falls we can demonstrate that reasonable measures have been
taken to protect patients from injury.
145
Key Words: risk, fall, ophthalmological, nursing, eye diseases, standardized measuring
instruments
INTRODUCTION
In the context of health, the concept of risk is closely linked with the pursuit of global health
in
order
to
ensure
the
safety
of
medical
and
nursing
care.
Risk is something that can happen, and if "something" happens, someone or something will
be negatively affected. "Aim of medical care is to provide quality and safe care to all patients
and ensure effective communication with members of their families. This includes not only
the technical aspects of care, but also access to care, provision of early care and human
approach to clients" (Škrla, Škrlová, 2008, p. 43).
A patient survives most of the time during hospitalization at the nursing unit. For this reason
nursing staff must have a system in which they have a perfect view of each patient and the
risks that could lead the patient to the fall not only during the hospitalization but they could
also
threaten
the
patient
on
his/her
life.
(Frantová,
Beťková,
2010).
A systematic and organized approach to reducing the risk of falls can help concentrate
resources for patients who are at greatest risk. By creating, compliance, documenting the
procedures which lead to the assessment of the risk of falling and by reducing the number of
falls, the health care institution can demonstrate that it has taken reasonable measures to
protect their patients from accidents (Poledníková, Slamková, Molnárová, 2009).
The prevention of falls is based on the assumption of an identifiable etiology of the most
probable cause, it is understood as a multidisciplinary risk assessment and strategies in order
to put into practice effective preventive measure, with the participation of the entire health
care team, who together are responsible for the safe environment of their clients
(Poledníková, Slamková, Molnárová, 2009).
METHODS
As the main method we used interrogation method and observations through standardized
measurement scales.
By admission of the patients we used in all n = 90 respondents Gait functional test to
determine the balance and prevention of falls. The test was easy and time-saving. The test
contains four items in which the method of observation among respondents monitored sitting,
standing, walking and turning around. If the patient is able to meet all four tasks without
146
losing balance, staggering, falling or searching objects on which the patient could fall back or
lean against, then the Gait test is negative. If the patient is unable to complete the test, or
he/she has the above-mentioned problems, it is necessary that a nurse will initiate a protocol
of fall prevention. Screening test to determine the risk of falling, which can be used to assess
the risk of falling during nursing history was chosen as another measurement range. The test
contains six items with which we investigated the respondent's motion, emptying, medication,
sensory disturbances, mental status and age. Evaluation is based on the census of points and
then by comparing the set of scoring the test: with the score 3 or more, it is necessary to take
measures designed to prevent a fall. Gait functional test, screening test belong to the tests that
are applicable in practice. They are not time-consuming and allow nurses to assess the
expected risk of falling and then provide measures to prevent the patient from falling
(Frantová, Beťková, 2010).
The obtained data were processed and evaluated by the method of quantitative and qualitative
analysis.
Individual
data
were
visualized
using
tables
and
graphs.
Inductive statistics was used as the statistical method. We tested statistical significance of
differences in the groups using the method of Chi-squared test. We examined the risk of
falling due to age, and the risk of falling due to their stated diagnosis using statistical
processing method of T-test. The research was done at the ophthalmological clinic at the
University Hospital in Nitra in the time period from November 2011 to March 2012.
RESULTS
The basic criterion of the research group of respondents was hospitalization at the Eye Clinic
of the University Hospital in Nitra. Sampling was intentional, it consisted of n = 90
respondents in the age range from 45 years to life longevity. According to age criterion
dominated respondents aged "45-74 years" n = 47 (52 %) and respondents aged "75 and over"
n = 43 (48 %) of respondents. Selection criteria were respondents with medical diagnoses:
cataract, age-related macular degeneration (ARMD below), diabetic retinopathy (DR below)
at the time of research hospitalized at the Eye Clinic in Nitra. On the basis of the selection
criteria we have established research sample n1 = 30 (100 %) of respondents with a medical
diagnosis of cataract, n2 = 30 (100 %) of respondents with a medical diagnosis of ARMD,
n3 = 30 (100 %) of respondents with a medical diagnosis of DR. Respondents were contacted
individually directly at the eye clinic during the anamnestic interview, the patients were
acquainted with the research, its objectives and the manner of recording.
147
The main objective of the research was to study risk management in the fall of the ophthalmic
patient during hospitalization through standardized measurement techniques.
By specifying the main objective, we came to the following sub-objectives: To evaluate the
risk of falls in hospitalized ophthalmic patient with respect to age of the patient and to
evaluate the risk of falls in hospitalized ophthalmic patient in relation to medical diagnosis.
We assume that the risk of falling will increase with patient age and we assume that the risk
of falling is higher for respondents with a medical diagnosis of cataract than those with the
ARMD and DR.
Analysis of Gait functional and analysis of Screening test to determine the risk of falls
Using Gait functional assay of screening test to determine the risk of falls, we investigated the
risk of falls in relation medical diagnosis Cataract, AMD, DR in relation to the below
mentioned age groups.
Table 1: Evaluation of Gait functional test in medical diagnosis of Cataract,
AMD, DR in relation to the below mentioned age groups.
Gait functiona
test
Cataract
age
45–74 years
75 and
more y.
In total
ADM
DR
negative
n1
%
6
20
2
7
positive
n1
%
8
27
14
46
negative
n2
%
10
33
4
13
positive
n2
%
5
17
11
37
negative
n3
%
12
40
5
17
positive
n3
%
6
20
7
23
8
22
14
16
17
13
27
73
46
54
57
43
If the patient is able to handle this activity without losing balance, staggering, falling or
searching for objects which could support his balance, then the test is negative. If the patient
is unable to complete the test or he/she the above mentioned problems, the test is positive.
Table 2: Evaluation of Screening test to determine the risk of falls in the medical diagnosis of
Cataract, AMD, DR in relation to the below mentioned age groups
Screening test
risk of falling
test
points
Cataract
age
45–74 y.
75 and more y.
In total
n1
6
2
8
negative
0-2
%
20
7
27
ADM
positive
3 and
more
n1
%
8
27
14
46
22
73
DR
negative
0-2
n2
12
2
14
%
40
7
47
At score 3 and more the test is positive.
148
positive
3 and
more
n2
%
3
10
13
43
16
53
negative
0-2
positive
3 and more
n3
8
5
13
n3
10
7
17
%
27
17
44
%
33
23
56
From the results of the findings of Gait functional test in medical diagnosis of Cataract,
AMD, DR in relation to the above mentioned age groups, we found a significant increase in
the number of the respondents with a positive test at the age group of 75 years and older with
a diagnosis Cataract. Simultaneously by evaluating the Screening test to determine the risk of
falling in medical diagnosis Cataract we found out exactly the same sequence between
medical diagnoses in the negative and positive test results as it was in the Gait functional test.
These findings are related to a higher average age in the diagnosis of Cataract (76.5 years) and
the lowest average age in DR (70.4 years), in the AMD (74.5 years).
The achieved level of significance of the Chi-squared test in the Gait functional test was
p = 0.001151 and in the screening test of the risk of falling the level was p = 0.000829, that is,
in both tests the level was significantly less than the 0.05 - and thus it is a statistically
significant result. We noted that among the observed groups, there is a statistically significant
difference. This finding confirmed our first hypothesis that the risk of falling will increase
with the age of the patient.
Based on the results, we found that out of the surveyed sample of the population of the 55
positive respondents, the positivity of the Screening test of the risk of falls was most
represented in the medical diagnosis of Cataract in 22 (73 %) of the respondents.
Of the surveyed sample of the population in 51 positive respondents (57 %), the positivity of
the Gait functional test was also represented in medical diagnosis of Cataracts in 22
respondents.
We came to a statistical comparison of Chi-squared by the values of the Screening test of the
risk of falls between individual diagnoses. By comparison we reached the level of
significance of Chi-squared test: in Cataract and AMD p = 0.107967, in Cataract and DR p =
0.17595 and in the AMD and DR p = 0.79525. The reached level of significance of Chisquared test when comparing among the three diagnoses was greater than 0.05 and therefore
statistically insignificant. The conclusion of the test was: " The risk of falling among the
respondents is independent of diagnosis."
By statistical comparison of Chi-squared by the test values of Gait functional test, we found
that the reached level of significance was: in Cataracts and AMD p = 0.108; in Cataracts and
in DR p = 0.018 and AMD and DR p = 0.438. The reached level of the significance of Chi149
squared test was statistically significant because we observed that the risk of falls is higher for
respondents with a medical diagnosis of Cataract than with diagnosis of DR.
The reached levels of significance of the T- test in the relation of Cataract and AMD was
p = 0.025 and in Cataract and DR p = 0.004, which is less than 0.05, and the levels are
statistically significant. Based on the above findings, the risk of falls is higher for respondents
with a medical diagnosis of Cataract than the AMD and DR.
Table 3: Risk of falls in relation to medical diagnosis
Screening test of the risk of falls
Diagnosis
Cataract
n
%
negative
8
27.00 %
positive
22
73.00 %
ADM
n
%
14
47.00 %
16
53.00 %
DR
n
%
13
44.00 %
17
56.00 %
∑
n
%
Significance of Chi-squared test:
0.235
Significance of Chi-squared tests:
35
39.00 %
expected frequency
p>
11.666664 11.666664
0.05
11.666664
0.108 = Cataract + ADM
0.176 = Cataract + DR
0.795 = ADM + DR
55
61.00 %
∑
30
100
%
30
100
%
30
100
%
90
100
18.333333 18.333333
18.333333
Gait Functional Test
Cataract
N
%
negative
8
27.00 %
positive
22
73.00 %
ADM
N
%
14
47.00 %
16
53.00 %
DR
N
%
17
57.00 %
13
43.00 %
∑
N
%
51
57.00 %
Significance of Chi-squared test:
0.058
p>
0.05
39
43.00 %
expected frequency
12.999999
12.999999 12.999999
Significance of Chi-squared tests
0.108 = Cataract + ADM
0.018 = Cataract + DR
0.438 = ADM + DR
Diagnosis
DISCUSSION
150
16.999998
16.999998
16.999998
∑
30
100
%
30
100
%
30
100
%
90
100
The main objective of the survey was to map the risk management in the fall of ophthalmic
patients in the hospital using the standardized measurement techniques. The health status of
ophthalmic patients with visual perceptual impairment requires special care, especially
accompany in an unfamiliar environment, prevention of falls and injuries.
From the findings by Gait functional test in medical diagnosis Cataract, ARMD, DR in
relation to these age groups we have discovered a significant increase in the number of
respondents with a positive test at the age group 75 years and over Cataract n1 = 14 (46 %) of
respondents ARMD n2 = 11 (37 %) of respondents and DR n3 = 7 (23 %) of respondents.
Conversely, the highest number of respondents was recorded at the age group of 45-74 years
with a negative test result at DR n3 = 12 (40 %) of respondents, then at ARMD n2 = 10 (33
%) and finally in cataract n1 = 6 (20 %) respondents. In the evaluation of the screening test in
order to determine the risk of falling in medical diagnosis of cataract, AMD, DR in relation to
those age groups exactly the same sequence was confirmed between medical diagnoses by the
negative and positive test results as using Gait functional test. These findings relate to the
higher age average in cataract (76.5 years) and the lowest average age in DR (70.4 years),
with ARMD (74.5 years).
We have found that from the group of 55 respondents with positive results of screening tests
for risk - in particular 34 respondents (79 %) at the age group of 75 years and older and 21 (45
%) of respondents at the age of 45-74 years have a higher risk of falls. Out of the total number
of the respondents 35 with negative results - without the risk of falling achieved 26 (55 %)
respondents at the age group from 45 to 74 years and only 9 (21 %) of the respondents aged
75 and over.
Out of the 51 respondents, 32 (74 %) respondents at the age group of 75 years and over and
19 (40 %) of the respondents at the age from 45 to 74 years reached a positive result of the
Gait functional test - failure to maintain the balance of the body. Out of total number of 39
respondents, 28 (60 %) respondents at the age group of 45-74 years and over and 11 (26 %) of
respondents aged 75 years and over had a negative result – without balance failure.
The achieved level of significance of chi-square test in both tests p = 0.001 and p = 0.001 is
substantially smaller than 0.05 – it is statistically significant. We note that among the
observed groups, there is a statistically significant difference, which confirmed our claim that
the risk of falls will increase with the age of the patient.
151
We have identified ourselves with the view of Hegyi, Krajčík (2010) that crashes occur when
the mechanisms which keep the balance cannot correct the rapid change in position. During
aging, there is an increasing incidence of falls which rise from internal causes. These falls are
accompanied by the failure of mechanisms which sustain balance. Wojszel and colleagues
(2001) confirm that an advanced age may be included among risk fall factors.
Svobodová (2012) states in the project called "Monitoring of falls in hospitalized patients in
2011-2012" that the total number of hospitalized patients in 2011 was 790.006, out of which
288.542 (37 %) were aged over 65 years. Paramedics recorded in total 8558 falls, the
proportion of patients aged over 65 years to the total number of patients was 37 %; the share
of the falls in the number of patients aged 65 years and more 3 %, which corresponds with our
findings.
The problem with sensory perception in her survey indicates Bartošová (2011) 63 respondents
out of which 42 % outperformed the fall in the last year. She states that mainly men with a
diagnosis of Cataract had the problems.
Using measurement tools to assess the risk of falls in nursing practice is recommended by a
number of authors (Škrla, Škrlová, 2008; Hegyi, Krajcik, 2010; Frantová, Beťková, 2010;
Poledníková, Slamková, Molnárová, 2009.)
CONCLUSION
"A positive attitude of paramedics towards the safety of their patients is becoming an absolute
priority, which is constantly looking for new ways to improve the security of the entire system
of care" (Škrla, Škrlová, 2003, p. 127). By this contribution we would like to point out that
most falls can be prevented by providing high quality and targeted prevention. "By creating,
compliance, documenting the procedures leading to the assessment of the risk of fall and
reducing the number of falls, the health facility can demonstrate that it has taken reasonable
measures to protect their patients from accidents" (Poledníková, Slamková, Molnárová,
2009).
REFERENCES
BARTOŠOVÁ, K. Falls in geriatric Patients - Assessment of Risk Factors Found in a Selected Screening
Methods. Bachelor Thesis. [online]. [cit. 2014-07-04]. Available at:
https://dspace.upce.cz/bitstream/10195/39088/1/BartosovaK_Padygeriatrickych_MJ_2011.pdf
FRANTOVÁ M., BEŤKOVÁ, M. Prevention of Falls in Hospitalized Patients. Nurse and Doctor in The
Practice. ISSN 1335-9444 2010, vol. IX, no. 1-2, p. 14-15
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HEGYI, L., KRAJČÍK, Š. Geriatrics 2010. Bratislava: Herba, 2010. 608 p. ISBN 978-80-89171-73-6.
JOINT COMMISSION RESOURCES. 2007 Prevention of Falls in the Medical Device Path to Excellence
and Quality. 1st ed. Praha: Grada Publishing, 2007. 172 p.
ISBN 978-80-247-1715-9.
MASKÁLOVÁ, 2008 E. safe. In Tomagová, M., Boříková, I. et al. 2008 Needs In Nursing. Martin: Osveta,
2008 ISBN 978-80-8063-270-0. with. 122-127.
Monitoring Falls In Hospitalized Patients In 2011-2012. Final Report. Prague, Linet. TIME,
2013, 31 p. [online]. [cit. 2014-09-20]. Available at:
http://www.cnna.cz/docs/tiskoviny/zaverecna_zprava_2011_2012-91b6f.pdf
Meridian, Ľ. - Slamková, A. - MOLNÁROVÁ, J. The Role Of Nurses In The Prevention Of Falls And Injury
In Older Age. Nursing In The 21st Century In The Process Of Change III. Proceedings Of The International
Symposium [CD]. Nitra: Faculty of Social Sciences and Health, Department of Nursing UKF Nitra, 2009, p.
708-723. ISBN 978-80-8094-554-1.
WOJSZEL, B., Bien, B., PRZYDATEK, M., Wielkie geriatryczne problems. In Health Practitioners
Rodzinna. ISSN 1505-3768. , T.13, 2001 n. 2, p. 83- 86
The paper is supported projects KEGA MŠVVaŠ No. 050UK-4/2013. - Multimedia e-textbook nursing
procedures special surgery.
CONTACT AN AUTHOR
Dr. Jozefína Mesárošová, PhD.
Department of Nursing FSVaZ UKF
Kraskova 1
949 74 Nitra, Slovakia
153
THE PREVENTION OF SORRORIGENIC WOUNDS IN INTENSIVE
CARE
Pokorná, Andrea. Blatnerová Hana.
Department of Nursing, Faculty of Medicine, Masaryk University, Brno
ABSTRACT
Background: Sorrorigenic wounds in intensive care are increasing issue with the respect to
the high demands on a quality and safety of the care. Therefore, the main objective of this
research paper was to assess the knowledge and habits of general nurses in this area.
Methods: The quantitative research in general nursing areas working in intensive care
settings and A&E (Accident and Emergency department) was applied. The main objective of
this research was to map their knowledge and habits in sorrorigenic wounds prevention. Data
analysis was completed using second class analysis (Kruskal-Wallis test, Wilcox test,
Pearson’s chi-squared test and Spearman correlation coefficient) with the significance level of
0.05.
Results: 149 nurses were evaluated based on their knowledge and behaviours. The results
indicated significant differences in nurses’ knowledge of sorrorigenic wounds prevention
based on their employment type (p = 0.02) and also wound dressing practices based on a type
of employment (the timing of a wound dressing p = 0.0006; wound dressing personal (p <
0.000). Also significant differences in a personal competence of nursing staff were found and
their acceptance by doctors in the prevention and treatments of wounds based on the type of
their employment (p < 0.000). The previously discussed situation was generally positively
evaluated by nurses from A&E.
Conclusion: The issue of sorrorigenic wounds has not been appropriately discussed so far,
neither on scientific/academic or clinical levels. Most of the respondents were able to identify
types of sorrorigenic wounds, but were unable to identify the risks and adequate prevention
steps. The result of this effort is an establishment of a suitable clinical procedure of
sorrorigenic wounds prevention in intensive care with the identification of perilous
interventions and processes.
Key Words: sorrorigenic wound, general nurse, intensive care, prevention.
154
INTRODUCTION
Sorrorigenic wounds are caused by negative activities of hospital personal (Koutna, Pokorna,
2013, pp. 26 – 28). The scientific name sorrorigenie comes from Latin-Greek terminology. Its
basis is a Latin term sorror = sister and a Greek term gennao = do, inflict. This interpretation
describes the damage to a patient caused by an undesirable behaviour of a general nurse
(Mares, Pecenkova, Spoustova, 2002, p. 8).
Sorrorigenic wounds are an increasing problem in current intensive care settings with respect
to the quality and safety of hospital care. At the moment the problematic subject of nonhealing wounds is often discussed. An interest in new information and education regarding
this problematic area constantly increases not only from healthcare professionals’ side, but
also from laics too.
The treatment of wounds of patients in intensive care has specific characteristics, which are
then used for a therapy strategies and a choice of dressings. Sudden acute changes in the
health state of originally compensated patient can lead to stagnation or worsening of wound
healing. This situation is not helped with the use of otherabnormal entrance paths (invasive
entrance and derivative entrance, drains etc.) into the organism of a patient, which are
necessary for the monitoring of vital functions or the performing of single or repeated
examinations (Koutna, Pokorna, Ulrych, 2012, pp. 22 – 27).
The most important rule of sorrorigenia is prevention. The quality of nursing careis extremely
important. The most important aspects of high quality nursing care during overall
hospitalisation period include;a careful record keeping and a persistent evaluation of
documentation, a consistent completing of surgery hours, an application and procedures by
specified standards, a facilitation of gentle care and psychological support, a protection of all
standards regarding healthcare equipment regulations, an appropriate work organisation, the
communication with the patient and also the communication within healthcare personal
(Morovicsova, p. 22 – 23).
There are many factors that are involved in sorrorigenic wounds formation. One of these
factors is a sustained pressure on vulnerable areas of the body. Vulnerable areas are all parts
of the body, which have low depositions of fat (mainly prominent bony projections).An
inadequate or long-term unchanged position gives a rise to pressure sores that are mostly
found in the area of sacrum, heels, shoulder blades, and elbows, knees, above the greater
155
trochanter and on an inner and outer side of ankles. Other reasons for a wound development
can also be the pressure of tools under the patient, a friction with additional action of shearing
forces during positioning of the patient, moisture, a rough fixation removal, a vital functionmonitoring equipment during prolonged attachment on a certain part of the patient’s body,
frequent changes of a wound dressing, an unsuitable choice of a wound-dressing therapeutic
material, an inappropriate use of anti-decubitus tools (a ring cushion type), a prone position
and many more (Koutna, Pokorna, Ulrych, 2012, pp. 22 – 27; Hasova, Marsalkova, 2012, pp.
22 – 23).
The main aim of the presented research was to discover the knowledge and habits of general
nursing staff working in A&E and ICU in relationship to the issue of sorrogenic wounds in
intensive care and to discover determining factors of their knowledge level. At the same time,
the aim was to assess professed habits of nursing staff working in A&E and ICU in prevention
of sorrogenic wounds in intensive care settings and to evaluate different subjective opinions
of general nurses working in A&E and ICU on the level of a recognition by doctors in a
prevention process and a treatment of a non-healing wound in intensive care. The basic
premise of this paper was that an education, the length of a practice, the type of department
will affect the range of knowledge and habits of respondents working in wound patient care
settings. The assumption also was that declared habits (the time and person, on whom the
respondent performsa replacement of a wound dressing) and the type of department (A&E
and ICU) do not depend on each other. Another assumption was that the subjectively
perceived level of respondents’ knowledge and the subjective assessment of a competence are
not dependent on each other and that the subjective opinion of respondents on the level of
acceptance by doctors working in the area of prevention and treatment of non-healing wounds
and the type of department (A&E and ICU) will not be affected by respondents’ working
place.
METHODS
The research survey (22 items) evaluated the level of knowledge and the level of declared
practical habits of paramedical healthcare workers (a general nurse, health care assistant
andparamedic) working in intensive medicine departments of a wound care, also as a
competence assessment and knowledge of non-healing wound-care processes and the level of
an acceptance by doctors in the prevention and treatment of chronic non-healing wounds in
such a way, so the objectives of this research can be concluded.
156
The research was completed in the intensive care unit of Surgical clinic, Gastroenterological
clinic, Orthopaedic clinic and Accident and Emergency clinic, also the Clinic of
anaesthesiology, resuscitation and intensive medicine of University Hospital of Brno (UHB),
at which according to earlier investigations, the paramedical healthcare workers come
relatively often in contact with non-healing wounds and moist healing methods. The choice of
respondents was deliberate. The questionnaire distribution and data collections were
completed in the period between 20. 11. 2013 and 20. 01. 2014.
The hypothesis statistic testing was performed with the help of several tests such as the
Kruskal-Wallis test, Wilcox test, Pearson’s chi-squared test and Spearman correlation
coefficient and Kolmogorov-Smirnov test with significant level of α = 0.05. If the p-value
would not reach over the asymptomatic level of its significance 0.05, the null hypothesis
would be rejected.
RESULTS
In total, there were 180 questionnaires distributed to specific UHB clinics with the respect to
the overall number of healthcare workers. 156 questionnaires (86.7 % yield rate) were
returned. Seven questionnaires were removed from the data analysis due to the incomplete
filling or a declaration of not using the moist methods of wound healing in their work
department. The final number of used questionnaires was 149 (100 %). For the research
respondents were chosen from two types of departments. There were 71 respondents (47.65
%) working on A&E and 78 respondents (52.35 %) on ICU. This nearly equal distribution
was generated randomly and was not influence by a deliberate choice. From the demographic
data was found that the average age of respondents is 31 years. The most represented group
were respondents with the length of a professional practice of 6 to 10 years (n = 52; 34.9 %).
On the contrary the least marked group formed respondents with the professional practice
length from 21 years up (n = 6; 4.03 %). The average interval of a respondent practice was 9
years (min. 0 years and max. 30 years). The most common form of a highest education of
respondents was a college training - a general nurse (n = 61; 40.94 %). Another large group
formed respondents (n = 40; 26.85 %) with higher education in nursing – a nurse with a
diploma. A bachelor degree in nursing absolved 30 interviewees (20.13 %); a master degree
in nursing obtained 14 interviewees (9.4 %). Only 4 respondents (2.68 %) said to have a
college as their highest education level such as a healthcare assistant.
157
One of the knowledge questions asked the respondents about the term of a sorrorigenic
wound. Altogether 126 respondents (39.62 % answers) believed that the term represented a
decubitus wound. Additional 57 respondents (17.92 % answers) pointed at the term of
haematomas. Almost in the same number were labelled the probabilities of an excoriation (n
= 44; 13.84 % answers) and moist lesions (n = 43; 13.52 % answers). 12 respondents (3.77 %
answers) had no answer to this question. The data indicate that respondents are not aware of
possible sorrorogenic wound types. Certain significant inadequacies were discovered in
respondents’ habits of a management and application of derivative ointments locally on a skin
and in the use of anti-decubitus ring cushions. Most respondents (88 interviewers, 59.06 %)
use derivative ointment treatment only for some patients. The ointment is not used only by 33
respondents (22.15 %), on the contrary 24 respondents (16.11 %) always use the ointment. It
is important to say that the obtained data shows that the main part of respondents from the
A&E does not use derivative ointments compared to respondents that work in the ICU
department, which use derivative ointments always or only with certain patients. The data
analysis showed the same results in the investigation of the use of anti-decubitus ring
cushions. Overall 80 respondents (53.69 %) declared the use of anti-decubitus ring cushions
only sometimes, other 56 respondents (37.58 %) stated touse ring cushions always and only
12 respondents (8.05 %) never to use them at all. From the established records can be clearly
understood that respondents from A&E use anti-decubitus ring utilities in a lesser extend or
not use at all compared to the respondents from ICU. With regards to the above and also blow
presented results we can say that knowledge in the field of prevention of sorrorigenic wounds
are inadequate. Respondents are using derivative ointments, while 71.55 % is applied they to
larger areas and even 17.24 % by them gently massage predilection sites of sorrorigenic
wounds. Further proof of sufficient preventive knowledge is declared by declared
effectiveness of donut (ring) anti-decubitus utilies (wheels and rollers) which correspond to
the findings in relation to their subsequent use for patients.
From the knowledge evaluation point of view with the help of a point scoring of knowledge
elements and the basic school grading scale corresponding with the stage of primary and
secondary schools found that the knowledge of respondents did not significantly differ. The
knowledge test was focused on the evaluation of expertise in the definition of sorrorigenic
wounds, of its causes, symptoms and manifestations and prevention in the form of local and
systemic therapy. Special attention was paid on knowledge concerning the role of nurses in
prevention of sorrorigenic wounds (e.i. appropriate hygiene regime, using of preventive
158
strategies – locally /anti-decubitus utilies/ and systematically /physical therapy – light therapy,
nutritional support/, monitoring of symptoms and their early recognition. The lowest level of
the knowledge were found in the area of usage of preventive utilies, appropriate skin
protection creams and support of nutrition. In relation to the nutritional support there could be
explanation that it is under the prescription of physicians but the nurse's role is relevant
because she provides information about the patient's condition. Respondents were also
evaluating their level of knowledge – average mark of subjective evaluation of knowledge
was equal to 2.89 (on the basic grading scale from 1 to 5). The average mark of objective
evaluation was equal to 3.28 and the median value to 3. The average score given to
respondents in the A&E was 3.04 and for the ICU respondents it was 3.5. The respondents in
general overestimated their knowledge. Or rather, they unfairly evaluated their expertise
better than it was then objectively verified. It corresponds also with their subjective evaluation
of their competencies in wound management. Average mark in the subjective assessment of
respondent´s competences was 2.68.
DISCUSSION
The research evaluated the knowledge of respondents and also their habits in the relationship
to the issue of sorrorigenic wounds. Given the scale of data obtained, only the most
significant findings will be discussed further, as they can affect the situation in a clinical
practice in a patient care of non-healing wounds in intensive care settings.In the case of the
achieved education of determinants, respondents with university education with MSc. title
(21.43 %) were given a distinction (mark A). The very good marks (mark B) were scored to
the respondents (21.31 %) with college education such as general nurses that also most often
got the mark C, 31.15 % respondents. Satisfactory (mark D) knowledge in the issue of
sorrorigenic wounds had respondents (19.67 %) with the college education as general nurses
and at the same time respondents (30 %) with higher professional education – diploma nurses.
Unsatisfactory knowledge (mark F) demonstrated respondents (24.59 %) with a college
education – general nurses. In the monitored file, the knowledge of the problem of
sorrorigenic wounds and achieved education levels are not dependent on each other (p =
0.39).It is essential to admit that the results could be affected by the composition of the
questionnaire, because the highest represented group were respondents with a college
education in the position of a general nurse. The reason could also be an inadequate general
knowledge of respondents in sorrorigenic wounds area. However, the results clearly indicate
159
that respondents with university education with master’s degrees have large awareness of
sorrorigenic wounds, which could be due to the fact that the issue of non-healing wounds is
included in their study programme and is a compulsory part of their education.
In the terms of the overall length of a professional practice,respondents with the length of
practice of 6 – 10 years were always the most numerously represented from all classifications
(A – F). A distinction mark achieve 7.69 % respondents, the very good mark had 19.23 %
respondents, a good mark 32.69 % respondents, a satisfactory mark had 23.08 % respondents
and an unsatisfactory mark 17.31 % of respondents. An important fact should be noted, the
mark A was given mainly to respondents with a shorter length professional practice. From the
established data can be generally understood that respondents with a shorter length of practice
were assessed higher in the knowledge tests than respondent with longer years in professional
practice. Respondents were represented in individual point systems almost from all categories
of professional practice. After the evaluation of the statistical analysis, it can be said that in
the given evaluated file the understanding of the sorrorigenic wounds issue and the length of
the professional practice are not dependent on each other (p = 0.58). One of the probable
explanations could be the respondents with a shorter length of a practice have a ‘fresher
knowledge’ stored in their memory compared to the respondents with a longer practice, which
have rather more developed their practical skills and abilities.The fact is, the issue of
sorrorigenic wounds was not included in training in the past and especially the issue of
sorrorigenic wounds has been recently discussed in the last few years.
In the case of the tested determinants on a work place type in a relationship to knowledge
proved respondents working in A&E better knowledge of sorrorigenic wounds than
respondents working in ICU. Based on the knowledge test, the mark A was given to
respondents (11.27 %) from A&E. The mark B was presented in the same representation to
respondents from A&E (22.54 %) and ICU (20.61 %). The mark C was the most often given
to respondents (30.77 %) working in ICU, as well as the mark D (26.92 %) and the mark F
(21.79 %). It can be said; the respondents from A&E achieved better results in the knowledge
test than the respondents from ICU. Another important fact includes respondents from A&E
that attained the maximum points in the knowledge test (4 points), while respondents from
ICU got only 3 points. Therefore,in the observed categorizer, the knowledge of sorrorigenic
wounds and the type of a working place directly depend on each other (p = 0.02).It’s possible;
the respondents working in A&E have greater interest in a postgraduate education and gaining
160
of specialisations in the field, compared to the respondents working in ICU. Also respondents
working in A&E care for their patients in more severe and live threatening circumstances,
therefore a high level of a professional understanding and skills is expected and also the
incidence of wounds is potentially higher – therefore are more experienced. Nonetheless,
respondents from ICU came from the internal department, also from the surgical department
and this fact could influence the results.
Another monitored parameter was the relationship between the types of work department and
stated habits during a change of a wound dressing. In declared habits was included a specific
time of day, designated for a change of a dressing and also a person, on whom respondents
carry out the dressing change. In the case of a dressing change times, from the collected data
was deduced that respondents working in A&E carry out the dressing change whilst doing a
patient’s personal care (47.89 %). On the contrary respondents working in ICU usually carry
out the dressing change in a specific time in afternoon (41.03 %). Koutna and Pokorna (2013,
p. 3 – 10) recommend that planned dressing changes should be completed in afternoon hours
during week days, if a situation allows, by an accredited nurse or by a professionally
specialised nurse in a wound healing. During weekends, the change of a dressing should be
carried out only in exceptional circumstances, according to the recommended care protocol or
in the case of a sudden change of a patient’scondition. The frequency of a wound dressing
changes should abide by an individual stated of the defect and by an attributed dressing
material. As a second the most frequent answer, nearly in the same number respondents from
A&E (30.99 %) and respondents from ICU (28.21 %) voted the opportunity was dependent on
their actual time options. In third place, respondents (21.13 %) from A&E voted the variant in
a designated time (late morning) and respondents (19.23 %) from ICU voted for the during a
personal care variant. Another option only voted respondents (11.54 %) from ICU, in which
they stated the by a doctor practice time option. A type of working place and time periods
designated for the wound dressing change do not differ (p = 0.0006). Due to the fact that in
Czech Republic (CZ) the normal care practice usually involves A&E nurse caring for only
one patient at the time, it can be said that nurses have more time to change a wound dressing
during a personal care, which is on many occasions quite time consuming. General nurses
from ICU treat two or three patients in the course of their shift, therefore do not have as much
time for a wound dressing change during a personal care. In addition, doctors especially from
surgical clinics carry out visits in early morning hours and then go to operating theatres, while
before that they want to be present during a dressing change of a non-healing wound.
161
In the case of a person with whom they perform a change of dressings, was found out that
respondents working in A&E mainly perform a dressing change with the help of a specialised
nurse trained in a wound healing (73.24 %), while respondents working in ICU (34.62 %)
said, using their own words used different combinations. The first combination given was;
they performed a wound dressing change on their own or with the help of professional (a
doctor or specialised nurse). The second combination involved wound dressing changes,
which are usually performed with the help of a nurse with special professional eligibility or
with the help of doctors. In second place voted respondents from A&E (14.08 %) and
respondents from ICU (26.92 %) the answer; on their own or with the help of a nurse. Next,
respondents from A&E (7.04 %) voted different option, in which they declared the already
mentioned combinations. Respondents from ICU (24.36 %) voted the possibility of an
assistance of a specially qualified nurse in wound healing. The least represented combination
choice in respondents from A&E (5.63 %) and respondents from ICU (14.1 %) was an answer
– with the help of a doctor. We therefore verified that the person with whom respondents
changed wound dressings significantly differ according to a workplace type (p = 0.00) and the
habits vary in different healthcare workplaces. The positive finding is that respondents
perform a wound dressing change with the help of a nurse specialised in wound healing, who
is a specialist in this area. An interesting finding is that respondents perform fewer wound
dressing changes with the help of a doctor. It is possible that doctors have different
responsibilities and have less time to spend with a non-healing wound dressing changes;
therefore nurses rather contact nurses – wound consultants. Another explanation is the nurses’
possibilities in absolving certified courses, technical seminars and activities in a lifelong
learning, and therefore doctors leave wound care areas to more actual erudite and competent
paramedical health workers. There is currently no complex and uniform system in doctors’
education in CZ in the areas of wound managementsat undergraduate or postgraduate levels.
The above facts confirm also findings in areas of a subjective evaluation of respondents’
knowledge and a subjective evaluation of a competence in the area of care for people with
chronic wounds. All respondents that evaluated their knowledge with a distinction mark rated
their competence with a distinction too; which also presented itself in another evaluation with
the use of marks according the general school criteria. In the case of respondents who rated
their knowledge very good, also the most frequently evaluated their competence very good
(73.17 %) and the same is the case of further evaluation of knowledge of respondents; good
(71.23 %), satisfactory (44 %) and unsatisfactory (60 %). From the data can be concluded that
162
in the dependence on knowledge evaluations are judged even competences that a subjective
evaluation of knowledge and subjective evaluation of competences are dependent on each
other (p = 0.00). In a survey completed by Bartlova and Hajduchova (2010, p. 28), whose aim
was to view relationships between general nurses and doctors, more than half of nurses (48.6
%) thought that the boundaries between doctors’ and nurses’ competencies’ are clearly
defined. Bartlova and Hajduchova also highlight that in the wound care nurses (14.1 %) are
given jobs, which do not completely fall into their competence. It is mainly in the case of
dressing changes and a wound care and the extraction of stiches. Also as the result from
different surveys there are continuing weaknesses in the acceptance of nurses’ knowledge and
skills in the team, not only in a relation to the wound management (Ousey, Cook, 2012, p. 2;
Cook, 2011, p. 40; McCluskey, McCarty, 2012, p. 37; Stremitzer et al. 2007, p. 143). The best
way how to help nurses in wound management and wound assessment is to prepare useful,
easy to use wound assessment tool. It helps either inexperienced staff in orientation and
decision making and acted as an aide memoir for experienced nurses (Padmore, 2009, p. 29).
This topic is connected to the last studied area, in which was evaluated the level of acceptance
by doctors in the non-healing wounds’ prevention and treatment by means of a workplace
type.
In case of the level of acceptance (via the five-level Likert classification) of non-healing
wounds prevention grated most of the respondents working in A&E (67.61 %) and ICU
(52.56 %) the level of acceptance - very good. In second place selected respondents from
A&E (23.94 %) a distinction in the level of acceptance, but respondents (28.21 %) from ICU
a good. In third place 5.63 % respondents from A&E graded the level of acceptance with very
good mark and 10.26 % respondents from ICU thought it only to be a satisfactory. The least
used evaluation mark from the questioners of A&E (2.82 %) was the level of acceptance
aassatisfactory and from ICU (8.87 %) was distinction. Respondents from A&E generally
assessed the level of acceptance by doctors higher than respondents from ICU (p = 0.000015).
It can be said that respondents working in A&E have rather high level of knowledge and
competences, which they proved in the knowledge test; they are more involved in
management of patient care, and therefore they believe that doctors have more confidence in
them. The area of a multidisciplinary cooperation on different types of working places ICU
and A&E would benefit from a special attention in follow up research, not only in the wound
management. In research concluded by Bartlova and Treslova (2010, p. 11) more than half of
nurses (54.8 %) said that doctors perceive them as their equal in patient care. Authors also
163
mention that the more education a nurse has the more acknowledged and accepted she is
which has been confirmed by earlier mentioned facts.
In case of the level of acceptance in the non-wound healing area treatment was discovered,
that respondents working in A&E (78.87 %) evaluated the level of acceptance by doctors by a
very good mark, the same result was found from respondents working in ICU (58.97 %).
Other numerically most frequent evaluations were from A&E (11.27 %) respondents on the
level of acceptance by doctors as a distinction mark respondents from ICU (23.08 %) as a
good. In third place, the most commonly reported respondents from A&E (5.63 %) the level
of acceptance as a good and respondents from ICU (15.38 %) as a satisfactory. Only 4.23 %
respondents from A&E reviewed the level of acceptance as satisfactory and only 1.28 %
respondents from ICU a distinction and satisfactory. Respondents from A&E generally rated
the level of acceptance by doctors in the treatment of non-healing wounds better than
respondents from ICU (p = 0.000006). The findings may be affected, as well as in the case of
the level of acceptance in prevention of non-healing wounds; by the fact thatrespondents
working in A&E have high levels of expertise and skills, become more involved in patient
care and therefore doctors have more confidence in them. In addition, doctors often don’t
orientate themselves in the methods of moist wound healing, also with respect to the contents
of undergraduate and postgraduate teaching in wound management.
CONCLUSION
The performed research established some significant deficiencies in knowledge of nonmedical healthcare workers (a general nurse, healthcare assistant and paramedic) working in
the intensive care, relating to sorrorigenic wounds. Similarly, deficiencies were discovered in
declared habits during care giving of non-healing wounds. Specifically, there was a lack of
knowledge in whole and local causes of sorrorigenic wounds, further of type of wounds,
which can be considered sorrorigenic, the knowledge of use and application derivative
ointments on patients’ skin and the using of anti-decubitus ring cushions in a work place. In
the context of proven knowledge were respondents working in A&E evaluated better than
respondents from ICU. Also incorrect and potentially damaging use and application of
derivative ointments and the use of ring cushions was less common in respondents from
A&E.
The research findings were given to the management of individual involved workplaces and
should serve as a tool for self-education and obtaining information to future and existing
164
healthcare workers in intensive care, which should use it in their practice. A recommendation
was provided for practice in form of a simple theme, which will enable the healthcare workers
from intensive care to ensure more effective prevention of sorrorigenic wounds and especially
will simplify the orientation in this problem, identification of risk interventions and will
secure efficient preventive-therapeutic strategies.
REFERENCES
BÁRTLOVÁ, S., HAJDUCHOVÁ H. Předávání kompetencí mezi lékařem a sestrou (Transfer of competencies
among nurses and doctors). Kontakt. 2010, vol. XII, no. 1, pp. 20 – 22. ISSN 1212-4117.
BÁRTLOVÁ, S., TREŠLOVÁ, M. Jak nahlížejí sestry na pracovní vztahy s lékaři (How nurses view the
working relationship with doctors). Kontakt. 2010, vol. XII, no. 1, p. 11. ISSN 1212-4117.
COOK, L. Wound assessment: exploring competency and current practice. British J of Community Nursing
Wound Care Supplement. 2011;16(12):40.
HAŠOVÁ, K., MARŠÁLKOVÁ, J. Hojení ran (Wound Healing). 1st ed. Ostrava: Ostrava university in Ostrava,
2012. 92 pp. ISBN 978-80-7464-114-5.
KOUTNÁ, M., POKORNÁ, A. Iatrogenic nursing wounds events in the intensive care (nurse caused wounds in
the intensive care). In: POSPÍŠILOVÁ, A., STRAKOVÁ, J., JUŘENÍKOVÁ, P., POKORNÁ, A.,
Conference Proceedings. 1st ed. Brno: Masaryk university, 2013. 50 pp. ISBN 978-80-210-6639-7.
KOUTNÁ, M., POKORNÁ, A., ULRYCH, O. Hojení ran v intenzivní péči I. (Wound Healing in intensive care
I). Hojení ran. 2012, vol. 6, no. 3, pp. 22 – 27. ISSN 1802-6400.
KOUTNÁ, M., POKORNÁ, A. Hojení ran v intenzivní péči IV (Wound Healing in intensive care IV). Hojení
ran. 2013, vol. 7, no. 1, pp. 3 – 10. ISSN 1802-6400.
MAREŠ, J., PEČENKOVÁ, J., SPOUSTOVÁ, V. Iatropatogenie a sororigenie aneb jak lze poškozovat člověka
(Iatropatogenia and sorrorigenia – how is it possible to harmpatients). 2nd ed. Praha: Vysoká škola J. A.
Komenského, 2002, 59 pp. ISBN 80-86723-00-3.
McCLUSKEY, P., McCARTHY, G. Nurses’ knowledge and competence in wound management. Wounds UK.
2012; vol. 8, no. 2, pp. 37-47.
MOROVICSOVÁ, E. Iatropatogénia, sorrorigénia a možnosti ich prevencie (Iatropatgenia and sorrorigenia and
its possible prevention). Sestra a lekár v praxi. 2008, vol. 7, no. 7 – 8, pp. 22 – 23. ISSN 1335-9444.
OUSEY, K., COOK, L. Wound assessment: Made easy. Wounds UK. 2012, vol. 8, no. 2, pp. 1- 4.
PADMORE, J. The introduction and evaluation of Applied Wound Management in nurse education. In: Applied
wound management part 3. Aberdeen: Wounds UK, 2009, pp. 28-30.
STREMITZER, S., WILD, T., HOELZENBEIN, T. How precise is the evaluation of chronic wounds by health
care professionals? Int Wound J. 2007; vol. 4, no. 2, pp. 142-145.
CONTACT AN AUTHOR
Doc. PhDr. Andrea Pokorná, Ph.D.
Masaryk university, Faculty of Medicine, Department of Nursing
Kamenice 3, Brno 625 00, Czech Republic
Tel. +420 549 49 6601
E-mail:[email protected]
165
NURSING INTERVENTIONS USED IN SURGICAL NURSING
PRACTICE
Pospíšilová Alena, Kyasová Miroslava, Juřeníková Pera, Surá Zdeňka, Mičudová Erna
Pospíšilová A., Kyasová M., Juřeníková P.: Department of Nursing, Masaryk University,
Faculty of Medicine
Surá Z., Mičudová E.: The University Hospital Brno
ABSTRACT
Background: The investigation was to identify the frequency of nursing NIC interventions at
surgical units of non-intensive care.
Methods: The information was obtained by a quantitative searching method using
questionnaires containing 101 NIC interventions. For these interventions, the respondents
expressed their opinions on frequency of interventions in surgical nursing practice. They used
the scale: used minimally once a day; used minimally once a week; used minimally once a
month; used occasionally – less than once a month; not used; the intervention is not within
nursing competences.
Results: 255 questionnaires filled in by nurses working without professional supervision at
surgical units of non-intensive care for at least one year were used for the investigation. 33
interventions were detected by 75 % respondents as being used in surgical nursing practice at
least once a week. Out of this number, 17 interventions were evaluated by 75 % as being used
minimally once a day. The following interventions were found to be the most frequently used:
7920 – Documentation (99.9 %), 6540 – Infection Control (99.2 %).
Conclusion: The selected 33 interventions and additional two interventions (2930 – Surgical
preparation and 5610 – Teaching: Preoperative), which were filled in by the respondents as
frequently used in the surgical practice but had not been tested, are going to be adopted,
within other research activities, to the conditions of the Czech nursing care and subsequently
to be applied in the clinical surgical nursing care.
Key Words: nursing interventions classification, NIC, surgical nursing, standardized nursing
language.
166
INTRODUCTION
The nursing interventions classification (furthermore NIC) is a summative standardized
classification of interventions implemented by nurses while providing nursing care. It has
been being developed at the Nursing Department, the University in Iowa, since 1987, and its
last 6th edition contains 554 nursing interventions (Bulechek et al., 2012, p. V).
In the NIC classification, a nursing intervention is classified as any care based on a clinical
judgement and knowledge, it is a nursing performance resulting in the improvement of the
client` s expected results (Buchelek et al., 2012, p. XV). Each of the interventions contains the
name, definition, code, activities and footnotes. The code, name and definition are written in a
standardized nursing language, which must not be changed and is used for the communication
in nursing care. The list of activities describes actions which have to be done to implement the
particular intervention. In the case of need, these actions can be changed to ensure individual
nursing care of patients. The footnotes present information on the development and testing of
a particular intervention (Buchelek et al., 2012, p. 2).
The orientation in NIC is enabled by the alphabetic order of the interventions, by the
interventions division into a taxonomic structure consisting of 7 domains and 30 classes, the
interconnection of nursing interventions with NANDA-1 nursing diagnoses and by dividing
the interventions according to their usability in various clinical specialties (Buchelek et al.,
2012, p. XVI).
Surgical nursing care, for which 82 nursing interventions were chosen, is one of clinical
specialties. (Buchelek et al., 2012, p. 433 – 424).
Surgical nursing care provides a highly complex care which is characterized by a wide range
of nursing interventions (Barry-Walker, Bulechek, et al., 1994, p. 265). Nurses at clinical
practice face the necessity to develop a clinical nursing judgement. The right consideration is
essential for the content and range of the nursing care provided. The development of clinical
nursing judgement is often very demanding, particularly for students and beginning nurses.
The NIC classification is a tool which can be a guide for nurses` development of a clinical
nursing judgement during the phases 3 and 4 of the nursing process (Kautz, Kuiper et al.,
2006, pp. 129-138, McCloskey et al., 1992, pp. 3-14).
The NIC implementation in the Czech Republic is complicated by a comparatively low
awareness of the professional public. In 2009, an investigation was performed showing that
167
the NIC concept had not been known to 84.47 % respondents – nurses (Pospíšilová, Kyasová
et al., 2012, pp. 421 – 433). It has been also found that NIC was the starting point for
recording nursing interventions only for 4.95 % respondents (Pospíšilová and Kyasová, et al. ,
2010, pp. 358-367).
The implementation of the standardized nursing language in clinical nursing practice is rather
formal and does not result in effective meeting the clients´ needs (Hůsková, Juřeníková, 2010,
pp. 25-31), and nurses do not have a positive attitude to nursing classification systems (Dolák,
Scholz, Tóthová, 2012, pp. 434-443).
The utilization of classification systems will significantly improve the accuracy and quality of
documentation of nursing diagnoses, interventions and results (Muller-Staub, 2009, pp. 9-15).
However, the implementation itself should be carefully considered and planned exactly in
advance in clearly defined steps (Muller-Staub et all., 2007, pp. 702-713).
The NIC application of nursing care in surgical units and ICUs is supported by IGA MZČR
(Czech Ministry of health) NF12078-4/2011. The Project has been implemented with the
support of the Nursing Department, Medical Faculty, Masaryk University, Brno, and the
University Hospital, Brno, since 2011. It should have been finished by December 2014. The
content focused on surgical nursing can be summarized in three phases:
Phase 1: selection of NIC interventions suitable for surgical clinical practice.
Phase 2: adoption of selected NIC interventions to the conditions of the Czech Republic.
Phase 3: implementation of the validated interventions in the surgical nursing practice.
The results presented in this contribution give information obtained in the Phase 1 of the
investigation of surgical nursing care.
METHODS
The investigation was focused on NIC interventions used in surgical non-intensive nursing
practice at least once a week.
The choice of the respondents was intentional. The total number of 29 health care facilities
were addressed. 11 facilities (including 7 university hospitals) promised to cooperate. 312
questionnaires were obtained from these facilities between April and December 2012. The
target group included nurses working without professional supervision at a surgical
department of non-intensive care for at least one year.
168
In the investigation, quantitative searching methods were used. The choice of the method was
inspired by Barry-Walker, Buchelek, 1994, pp. 261-268) and by an investigation performed
by Lee, Enjoo, MikYoung, (2006, pp. 108-117).
On the pattern of the above mentioned investigations, it was decided to use a questionnaire
searching method. As in the 5th edition (which was the latest accessible edition at the time of
the investigation), the NIC contained 554 interventions, the number of assessed interventions
was reduced. 101 interventions were chosen which were suitable for the purposes of our
investigation. For these interventions, a reverse translation of the names and definitions was
carried out. These names and definitions became a part of the questionnaire.
The reverse translation was performed as follows: the original text was translated by one
translator into Czech and the reverse translation into English was done by another translator.
Both translators were required to have some experience with the translation of texts with
medical topics. The final version of the questionnaire was checked by a professional in the
Czech language.
The use of these interventions was evaluated by the respondents at the following scale: used
minimally once a day; minimally once a week; minimally once a month; occasionally –less
than once a month; never; the intervention is not in the nurse´s competence. The
questionnaire included a part explaining the mission of the investigation and making the
respondents familiar with NIC. Furthermore, identification data about the respondents were
found out.
The target group consisted of nurses working without any supervision at a surgical
department of non-intensive care for more than one year.
The questionnaire underwent a detailed pilot study and preliminary research. The
questionnaire validity was tested by the focus group. The reliability of the investigation tool
was tested after the collection of 150 filled-in questionnaires; and by means of Cohen´s kappa
coefficient (SPSS 19) the mean kappa value of 0.836 was identified, which can be considered
as sufficient (Chrástka, 2007).
The health care facilities which, according to the information published by the Institute of
Health Care Information and the Statistics of the Czech Republic from 2010, had at least 500
acute care beds.
169
From the point of view of research activities, we were interested in how many interventions
are used minimally once a week. Therefore, the two groups used minimally once a day and
minimally once a week were fused for the purpose of this investigation.
The data obtained were processed by means of the programs MS Excel 2003 and are
presented in tables in which the relative frequencies are expressed from the data of the total
number of the assessed questionnaires (255).
RESULTS
255 questionnaires filled in by the target group could be used for the investigation itself. The
average age of the respondents was 35.35 years (median – 35; modus – 30; min. – 23; max.–
61). The respondents mentioned the number of years after reaching the qualification in the
range of 1 – 41 years (average – 14.72; median – 13; modus – 10). The average length of their
clinical practice was 14.43 years (median – 13; modus – 7; min. – 1; max.. – 41). The length
of the respondents´ clinical practice at a surgical department was between 1 and 41 years
(average – 12.39; median – 10; modus – 5).
The highest number of the respondents – 136 (53.5 %) achieved only secondary education.
The fewest respondents – 6 (2.4 %) achieved the academic Master degree. The Bachelor
degree was achieved by 23 (9 %) respondents and 42 (16.5 %) respondents finished the higher
secondary school. 48 (18.8 %) respondents passed specialization study. The specialization
education in the specialty of surgical nursing care was passed by 23 (9 %) respondents.
The goal of the investigation was to choose nursing interventions which are often used in
surgical nursing practice. The limit value determined that the particular intervention was
mentioned by at least 75 % respondents minimally once a week. 68 interventions which were
included in the testing did not meet this requirement, and, therefore, were not evaluated as
interventions frequently used in non-intensive surgical nursing care.
The total number of 33 interventions were evaluated by more than 75 % respondents as
interventions in the non-intensive surgical nursing care minimally once a week (after the
fusion of groups minimally once a day and minimally once a week) Seventeen out of these
interventions were evaluated by more than 75 % respondents as interventions used minimally
once a day.
The Intervention No. 7920 – Documentation – was the most frequently used intervention.
99.6 % respondents evaluated this intervention as an intervention used in their clinical
170
practice minimally once a week (the fusion of the groups minimally once a day and minimally
once a week). This intervention was even mentioned as an intervention used minimally once a
day by 99.2 % respondents. The second most frequent intervention, the intervention 6540 –
Infection Control – was chosen by 99.2 % respondents as an intervention used in their clinical
practice minimally once a week. This intervention was mentioned by 96.9 % respondents as
an intervention Medication Administration: Oral. However, if this intervention is taken into
account from the point of view of using minimally once a week, it will occupy the fourth
position (mentioned by 97.6 % respondents). The same number of respondents mentioned the
intervention No. 3440 – Care of Incision Site (surgical wound) as an intervention used
minimally once week. With regard to using the interventions minimally once a week, the
intervention 3590 – Skin Surveillance (98 %) – was chosen. However, this intervention was
evaluated as minimally once a day only by 83.9 % respondents. A relatively high number of
respondents (36) evaluated it as used less than once a day but minimally once a week.
Table 1: Interventions which were evaluated as used at the surgical department of nonintensive care minimally once a week
Code and Label
Interventions NIC
7920 –
Documentation 18
6540 Infection
Control 15
3590 – Skin
Surveillance 6
2304 – Medication
Administration:
Oral11
3440 – Incision
Site Care5
4200 – Intravenous
Terapy12
1400 – Pain
Management 19
1800 – Self Care
Assistance 6
2300 – Medication
Administration16
2317 – Medication
Administration:
Subcutaneous*
1876 – Tube Care:
Urinary 7
Aggregate:
min. once a
day and
min. once a
week ( %)
99.6
Minimally Minimally Minimally Occasionally Not Is not within Note
once a
once a
once a
( %)
used nursing
( %)
day ( %) week ( %) month (
( %) competences
%)
( %)
99.2
0.4
0
0
0.4
0
0
99.3
96.9
2.4
0.8
0
0
0
0
98
83.9
14.1
2
0
0
0
0
97.7
95.7
2
1.2
1.2
0
0
0
97.6
93.7
3.9
0
0.4
0
0
2
97.2
93.7
3.5
1.2
0.4
1.2
0
0
96.9
94.5
2.4
0.8
0
0.4
0
2
96.9
91
5.9
1.6
0.4
1.2
0
0
96.9
94.5
2.4
0.8
0.4
1.2
0.4
0.4
96.1
91.8
4.3
2.4
1.6
0
0
0
95.7
74.5
21.2
0.4
2
1.2
0
0.8
95.7
93.7
2
0.4
1.2
0.8
0
2
2314 – Medication
171
Administration:
Intravenous 11
4190 – Intravenous
Insertion 10
3540 – Pressure
Ulcer Prevention3
1870 – Tube Care 3
1450 – Nausea
Management *
6490 – Fall
Prevention 4
3500 Pressure
Management4
5270 – Emotional
Support18
1570 – Vomiting
Management*
1100 – Nutrition
Management8
5614 –Teaching:
Preoperative 3
7370 – Discharge
Planning 17
5606 – Teaching:
Individual 16
0740 – Bed Rest
Care 2
2380 – Medication
Management 11
5602 – Teaching:
Disease Process 12
6680 – Vital Signs
Monitoring 15
2315 – Medication
Administration:
Rectal *
3660 – Wound
Management 11
2313 – Medication
Administration:
Intramuscular*.
0450 –
Constipation
Impaction
Management 4
7690 – Laboratory
Data Interpretation
94.2
87.1
7.1
2
1.2
0.8
0
2
93.7
73.3
20.4
4.7
0.4
1.2
0
0
93.3
91.4
78
55.3
15.3
36.1
3.1
5.1
3.1
2
0
0
0
0.4
0.4
1.2
91.4
67.5
23.9
5.1
1.2
0
0
2.4
91.3
78
13.3
6.3
0.4
1.6
0
0.4
91
75.3
15.7
2.4
4.3
0.8
0
1.6
90.2
48.6
41.6
7.5
1.6
0
0.4
0.4
88.6
69
19.6
5.5
2.7
0.4
0.4
2.4
87.9
65.5
22.4
1.6
5.1
2.4
2.7
0.4
85.1
59.2
25.9
4.3
2.4
1.2
4.7
2.4
84.7
69.8
14.9
5.9
4.3
4.7
0
0.4
83.5
58
25.5
9
5.5
1.2
0
0.8
83.5
78.4
5.1
1.6
0.4
2.7
9
2.7
83.2
62
21.2
2.4
4.7
3.1
5.9
0.8
83.1
79.2
3.9
2.4
5.9
6.3
0
2.4
83.1
34.5
48.6
6.3
6.7
2
0
2
82.7
70.2
12.5
10.2
4.3
0.8
0
2
81.9
73.7
8.2
6.3
9
0.8
0
2
81.5
38.8
42.7
9.8
7.5
0.4
0
0.8
75.3
69.4
5.9
1.2
1.2
1.6
20.8
0
7
Total
33 interventions
Superscript number listed after the name of intervention presents a number of professional organizations have
indicated the intervention as crucial to their clinical area in the survey authors McCloskey, Bulechek, 1998, 6776 (interventions that are marked * have not been tested by the research team NIC).
Intervention highlighted in italics were selected in the survey authors Eunjoo, L., Mikyoung, L. (2006, p. 108117) between 68 interventions that are most commonly used in surgical nursing practice.
The intervention 2240 – Chemotherapy Management – was evaluated as the least frequently
used intervention at the l department of surgical non-intensive care. The option is not used – it
was given by 204 respondents. As the second least frequently used intervention, intervention
172
3302 – Mechanical Ventilation Management: Noninvasive, was evaluated. This non-invasive
intervention is not used by 166 respondents. As the third least used intervention, the
intervention 0940 was evaluated – the Care of a Traction/Immobilization Aid (135).
DISCUSSION
The studies performed to classify nursing interventions (NIC) according to their use in
individual clinical specialties are done by the researchers of the NIC development team. The
information on this process can be found in the 2nd edition of the NIC classification, further in
the studies by McCloskey, Buchelek: Nursing Interventions Core to Specialty Practice (1998,
pp. 67-76)and in the contribution A Description of Medical-Surgical Nursing by BarryWalker, J., Buchelek, M. et al. (1994, pp. 261-268). However, the classification of
interventions in groups according to the specialties is a continuous process which follows the
NIC classification development and the process can be observed in individual NIC editions.
According to the information published by McCloskey, Bulechek et al. in the contribution
called Nursing Interventions Core to Specialty Practice, the 33 interventions chosen for this
investigation as used minimally once a week in surgical clinical nursing practice can be
labeled as usable in the whole area of nursing care because 20 of these interventions were
found at least by 5 institutions as typical for their clinical nursing practice (Table 1, upper
index). It is obvious that the Intervention No. 1400 – Pain Management – can be regarded as
the most complex one. It was mentioned by 19 out of 39 professional organizations which
took part in the investigation performed by the NIC research team in 1995. In our
investigation, this intervention was labeled as used minimally once a day by 94.5 %
respondents. Other interventions frequently mentioned by professional organizations as
typical for their clinical area included: 5270 – Emotional Support and 7920 – Documentation.
These two interventions were labeled as typical for their professional area by 18 professional
organizations; in our investigation, both these interventions were also evaluated as
interventions used minimally once a day by more than 75 % respondents. From the
interventions which were evaluated as used minimally once a week by more than 75 %
respondents, the intervention No. 0740 – Bed Rest Care - was evaluated by the fewest
professional organizations (2) as typical for the particular clinical area. In the NIC team
investigation, the above-mentioned intervention was given as a key intervention for their
clinical area only by AMSN and National Association of Orthopedic Nurses (McCloskey,
Buchelek et al., 1998).
173
25 interventions which were chosen in our investigation as used minimally once a week in
surgical nursing practice were also found by the AMSN professional organization as typical
for surgical nursing practice. The remaining 8 interventions were included in the investigation
as a result of the preliminary research because it was supposed that they were frequently used
in surgical nursing practice and this assumption has been confirmed. It is interesting that two
of these 8 interventions were chosen, in the 4th NIC edition, as typical for surgical nursing
practice (2304 – Medication Administration: Oral, 2315 – Medication Administration:
Rectal). However, in the 5th edition, they were not given as typical for surgical nursing care
(Buchelek et al., 2008; McCloskey et al., 2004).
Enjoo, L., Mikyoung , L. (2006, pp. 112-114) published the overview of 68 interventions
which had been the most frequently used by nurses as interventions in surgical nursing
practice. 18 out of these interventions were also, in our investigation, chosen as interventions
used in the surgical nursing practice minimally once a week (Table 1, italics) In our
investigation, the intervention 7920 – Documentation – was evaluated as the most frequently
used intervention. In the investigation by Enjoo, L., Mikyoung, L. (2006, pp. 112-114) this
intervention occupied the 11th position and was chosen only by 49 % respondents.
Interventions 6540 – Infection Control – and 3590 – Skin Srveylance , which were evaluated
as the most frequently used interventions in our investigation, were not chosen in the above
mentioned investigation.
In the second edition of NIC classification, information was given on which interventions are
statistically more significantly used in both outpatient and inpatient care. Out of the 33
interventions chosen as used minimally once a week in surgical nursing practice, 21
interventions were more frequently used at inpatient departments. In none of the interventions
assessed, a more frequent use at outpatient departments was identified according to the 2nd
edition of NIC classification. In the most (19) of the 33 interventions assessed, a higher use
was noticed in the ICUs. On the other hand, in three interventions which are focused on the
clients´ education (5602 – Teaching: Disease Process, 5606 – Teaching: Individual; 5614 –
Teaching: Prescribed Diet), a significantly higher use was recorded at the departments which
do not provide intensive care (McCloskey et al., 1996, pp. 24-30).
Although the target sample of our investigation consisted of nurses who were employed at the
departments of non-intensive care, we obtained information from nurses working at surgical
ICUs. By means of Pearson´s chí-sqaure test, at the level of significance of alpha=0.05, it was
174
found out that 29 out of 33 interventions given in Table 1 were used as frequently at nonintensive care units as at intensive care units. Interventions 0740 – Care of a Bed-Bound
Patient, 6680 – Vital Signs monitoring, 7690 –Laboratory Data Interpretation – were
evaluated as the most frequently used at ICUs.
Within the investigation, 33 NIC were chosen which more than 75 % addressed nurses
regarded as interventions used minimally once a week in surgical nursing practice. However,
this information reflects a subjective affirmation of the respondents; therefore, it is possible
that we could get different results if an observation in real clinical practice was performed.
The questionnaire research method was used from two reasons. First, all the accessible
investigation focused on the choice of interventions typical for surgical nursing practice had
been performed by questionnaire investigation. Second, the original studies presenting
information on the NIC usability in surgical nursing practice were not unified. Therefore, it
was necessary to collect the most possible data from various health care facilities. On the
other hand, the investigation did not contain any items which would result in false positive
answers. The sufficient reliability of the questionnaire was also proven by the Cohen´s kappa
coefficient detection (average 0.836).
Another limit of the finding represents the fact that there may be nursing interventions which
are not frequently used in some clinical nursing specialties; nevertheless they can be regarded
as typical for a particular specialty (e.g. 6700 – Amnioinfusion in prenatal care) (McCloskey,
Buchelek, et al., 1998, pp. 67-76). It was focused on the choice of interventions used in
surgical nursing practice because surgical nurses have low awareness and experience of NIC
(Pokorná, Kréthová, 2088, pp. 43-47; Pospíšilová, Kyasová el al., 2012, pp. 421-433). It was
found suitable to deal with interventions which would be the most usable for nursing staff.
CONCLUSION
In the investigation, which was a part of a special support by IGA MZČR NF12078-4/2011),
33 interventions were chosen which were regarded by more than 75 % addressed nurses as
interventions used in their surgical nursing practice minimally once a week. According to the
information obtained from the respondents, it was decided to include two others: 2930 –
Surgical Preparation and 5610 – Teaching: Preoperative. These interventions will be dealt
with in the Phase 2 of the investigation and their content will be adopted to our conditions.
The final interventions obtained can be used not only for clinical training but for the
qualification and specialization training of nursing students as well.
175
The contribution is dedicated to the IGA MZČR NF12078-4/2011 Project.
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2012, 14(4), 434 - 443.
HŮSKOVÁ, J., JUŘENÍKOVÁ, P. Analýza plánování péče o dýchací cesty v podmínkách intenzivního
ošetřovatelství. In JUŘENÍKOVÁ, P. et al. (eds). Sborník 5. mezinárodní konference všeobecných sester a
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reasoning with the Outcome-Present State-Test (OPT) model. International Journal of Nursing
Terminologies and Classifications. 2010, 17(3), 129-138.
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Korea and the United States. International Journal of Nursing Terminologies and Classifications. 2006,
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McCLOSKEY, J., BULECHEK, M. et. al. Nursing Interventions Classification (NIC). 1th ed. St. Louis: Mosby,
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NANDA and ZEFP. International Journal of Nursing Studies. 2007, 44(5), 702-713.
POKORNÁ, A., KRETHOVÁ, D. Možnosti využití NIC, NOC v hodnocení bolesti na Hematoonkologickém
oddělení. In BUŽGOVÁ, R., SIKOROVÁ, L. (eds). Ošetřovatelská diagnostika založená na důkazech II.
Ostrava: Repronis Ostrava, 2008. 43-47.
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s ohledem na vzdělání všeobecných sester. Kontakt. 2012, 14(4), 421-433.
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intervencí a očekávaných výsledků ošetřovatelské péče s ohledem na vzdělání všeobecných sester. In:
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CONTACT THE AUTHOR
Mgr. Alena Pospíšilová
Masaryk Univesity Faculte of Medicine
Departement of Nursing
Kamenice 3, Brno 62500; Czech Republic
[email protected]
177
SELECTED FACTORS AND THEIR IMPACT ON QUALITY OF LIFE
AND LIFE SATISFACTION IN PEOPLE WITH COELIAC DISEASE
Raková Jana, Tomašková Silvia, Dimunová Lucia
Raková J., Dimunová L.: Institute of Nursing, Faculty of Medicine, P. J. Šafárik University in
Košice,
Tomašková, S.: Hematology and Transfusion Casualty Treatment, Košice
ABSTRACT
Background: Our aim was to determine the influence of selected factors (coeliac disease and
other associated diseases) on the quality of life and life satisfaction in affected individuals.
Methods: Data collection took place in the period 10/2011 - 01/2012. We analysed 84
questionnaires distributed all over Slovakia to coeliac patients aged 18-70 years. The results
were processed in SPSS 18.0, applying methods of descriptive and inductive statistics.
Results: Differences in the quality of life in patients with coeliac disease were observed
under impact of other serious diseases (p < 0.001) in the subscale of physical functioning,
role-physical, bodily pain, general health, social functioning, vitality, mental health, in the
dimension of physical and mental health as well as in the scale of life satisfaction (p < 0.01).
Conclusions: Examined aspects should be taken into consideration in order to improve the
overall therapeutic and nursing care and thus quality of life in people with coeliac disease.
Key Words: quality of life, life satisfaction, coeliac disease, person with coeliac disease.
INTRODUCTION
Coeliac disease (CD), also called coeliac sprue or gluten-sensitive enteropathy is
a permanent, immunologically conditioned intolerance of gluten in genetically predisposed
individuals (Pekárková, Pekárek, Kabátová, 2009, p. 1; Kurppa et al., 2011, p. 83; Bézayová,
2013, p. 3). People suffering from the CD maintain their health condition thanks to the strict
gluten-free diet (GFD), which accompanies them throughout their whole life. GFD represents
a significant obstacle to achieving of personal goals and performing everyday life activities.
Epidemiological studies have shown that the CD is a common disease having worldwide
presence. Number of people with the CD in Europe is estimated around 3,000,000 (Frič, Keil,
2011, p. 354). In the Czech Republic and Slovakia, the prevalence of this disease is 1: 250,
178
which represents about 40,000 - 50,000 people (Makovický, Rimárová, 2011, p. 183).
Women are affected by the CD twice more often than men. The coeliac disease can be
diagnosed at any age and can be accompanied by different clinical manifestations and
complications. It is associated with an increased incidence of many other diseases, such as
iron deficiency, osteoporosis, and dermatitis herpetiformis as well as with many neurological,
psychiatric, endocrine and other autoimmune diseases. In clinical practice, we distinguish
between several forms of coeliac disease. Typical clinical symptoms of the CD (diarrhea,
weight loss, fatigue, abdominal pain, bloated abdomen, etc.) occur only in about 10% of
coeliac patients. Up to 90% of patients do not show any typical clinical symptoms (Green,
Jones, 2010). Biopsy of the small intestine is considered to be a standard procedure in the
diagnosis of the CD (Krajčírová, 2007, p. 268). In accordance with the above-mentioned
authors, Bézayová (2013, p. 4) specifies that histological and histochemical examination of
the sample taken from the small intestine is crucial for a definitive diagnosis. As part of the
coeliac disease treatment, a lifelong gluten-free diet is prescribed in order to keep the patient
with CD in remission.
CD represents an interdisciplinary problem (Makovicky, Samasca, 2013, p. 3-5) and except
for the dietary restrictions, it brings along physical, psychological and social issues that have
an impact on the quality of life (QOL) of affected individuals. QOL is a multidimensional
concept which does not have any universal definition. Technically speaking, the term QOL is
used to describe positive and negative aspects of life. The concept of QOL includes a wide
range of areas - from physical functioning to the achievement of life goals and experiencing
of life happiness. Nursing assessment of the QOL is based on a more narrow approach
towards the quality of life. It focuses on a person in a specific life situation in relation to
his/her health condition (Gurková, 2011, p. 25). When assessing the current QOL as a point of
departure for the health care, the main focus is put especially on the current hierarchy of
individual needs and their changing dynamics in somatic, psychological, social and spiritual
area (Hudáková, 2013, p. 13). QOL can be assessed on the basis of objective and subjective
approaches, the most important being a subjective assessment - how an individual sees
his/her own health situation, including the ability of self-realization in the work, family and
wider social environment (Slováček et al., 2005, p. 181).
The aim of our research was to determine the QOL of individuals with coeliac disease in
comparison with the general population. We equally investigated the differences in the
179
subjective perception of quality of life of coeliac patients and their life satisfaction in terms of
selected factors (other associated diseases).
METHODS
In order to achieve the given objectives, Satisfaction with Life Scale (SWLS) and a
standardized SF-36 questionnaire were used to collect researched data. Satisfaction with Life
Scale (SWLS) focuses on determining the overall life satisfaction. A validated Slovak version
of SWLS of the author Príhodová (2009, p. 104-106) was used in our research. It consists of 5
statements which can be marked on a 7-point Likert scale from the point 1 (strongly disagree)
to 7 (strongly agree). Summary score represents the value from 5 to 35, higher score meaning
higher life satisfaction. A generic tool used to measure the QOL The Short Form Health
Survey 36 items (SF-36) is often used to assess the QOL in relation with health. We used the
Slovak version of the questionnaire validated by Rosenberger (2009, p. 91-97) which contains
a total of 36 items divided into 8 subscales. Each item contains several answers based on the
principle of a rank scale. Respective subscales include: 1. Physical Functioning - PF, 2. RolePhysical – R-P, 3. Bodily Pain – BP, 4. General Health – GH, 5. Role-Emotional – R-E, 6.
Social Functioning - SF, 7. Vitality – V, and 8. Mental Health – MH. By combining of the
scores obtained in each subscale, we acquire the score in the dimensions of the overall
physical health (OPH) and overall mental health (OMH). The overall QOL index is found
within the range from 0 to 100, where higher values mean better health and better QOL.
For the cooperation in our research, we addressed coeliac patients who attend Slovak Coeliac
Association of Piešťany, civic association Celia in Žilina and Slovak Coeliac Association of
Trenčín. Data collection took place in the period 10/2011 - 01/2012. The research was
conducted by ourselves and also with the help of the presidents of the above-mentioned
associations. Data were assessed by means of the statistical program SPSS 18.0, applying the
methods of descriptive (N, Min., Max., Mean, standard deviation) and inductive statistics
(Mann-Whitney U test).
RESULTS
84 adult coeliac patients from all over Slovakia, aged 18 - 70 years, gave their consent to
participate in our research – their average age was 35.17 years (SD 2.37). In our researched
group, female coeliacs (87%) prevailed over male patients (13%), more numerous were
individuals living in a city (71%) and the most numerous group of coeliacs included people
180
with complete secondary education (49%) who were employed (66%) and living in marriage
(52%). In the part focused on the treatment of other serious diseases, majority of individuals
with the CD reported anaemia (25%), skin diseases (19%), thyroid disease (18%),
inflammatory bowel disease (8%), diabetes mellitus (1%). Among 'other diseases', they listed
allergy and osteoporosis. Compliance with the GFD is an important criterion and pillar of the
CD treatment. In our researched group, 48% of coeliac patients stated they did not violate the
GFD. 1% of coeliacs violate the GDF on a daily basis, 5% on a weekly basis, 21% on
a monthly basis and 25% of coeliac patients reported that they violated the diet unconsciously
or due to mislabelled food.
The below Table 1 shows the descriptive analysis of respective items in SWLS, SF-36
subscales and dimensions.
Table 1 Descriptive analysis: SWLS and SF-36 subscales (N = 84)
SWLS
PF
R-P
BP
GH
R-E
SF
V
MH
OPH
OMH
(N - number of respondents,
- standard deviation)
Min.
Max.
Mean
SD
8
31
20.87
5.34
13
30
27.71
3.18
4
8
6.86
1.47
3
11
8.65
2.27
8
25
15.54
4.28
3
6
4.92
1.29
3
10
7.39
1.89
4
23
14.16
4.04
10
28
20.08
4.53
31
74
58.76
9.56
23
66
46.61
10.43
min. a max. - minimum and maximum value of the summary score, mean and SD
The comparison of the achieved score in SWLS and SF-36 subscales based on the presence of
another serious associated disease tested by Mann-Whitney U test is depicted in Figure 1 and
Table 2.
70
60
50
absence of another
associated disease
40
30
presence of other
serious associated
diseases
20
10
0
181
Figure 1 Comparison of the score in SWLS and SF-36 subscales and dimensions in terms of
presence of other serious associated diseases
Table 2 Comparison of the mean score in SWLS and SF-36 subscales and dimensions
in terms of the presence of other serious associated diseases
Absence of another
associated disease
(N = 44)
Mean
SD
Presence of other
serious associated
diseases
(N = 40)
Mean
SD
p
SWLS
23.04
5.27
19.93
5.14
0.01**
PF
29.40
1.12
27.00
3.49
0.001***
R-P
7.64
0.91
6.53
1.55
0.001***
BP
10.16
1.31
8.00
2.29
0.001***
GH
18.60
3.57
14.23
3.89
0.001***
R-E
5.20
1.19
4.80
1.32
0.16
SF
8.52
1.45
6.92
1.87
0.001***
V
16.40
3.63
13.19
3.85
0.001***
MH
22.88
3.54
18.90
4.41
0.001***
OPH
65.80
4.92
55.72
9.50
0.001***
OMH
53.00
8.28
43.86
10.10
0.001***
***p < .001- high statistical significance, **p < .01 - moderate statistical significance
*p < .05 - low statistical significance, N - number of respondents, mean and SD - standard deviation
DISCUSSION
QOL of individuals with chronic diseases is subject to numerous factors. It depends on the
intensity, duration of symptoms - respective symptoms depending on the activity of the
disease, its forms, localisation, extent as well as possible complications. Although the CD
may not significantly limit the quality of life of an individual from the point of view of
physical condition, QOL is also significantly determined by psychological and social factors,
which in turn may affect physical condition of an individual. Adaptation to the disease and its
handling is largely influenced by significant lifestyle precaution - GFD. Nutrition, which
contains all the components required for the functioning of the organism, is an important
factor in health disorders (Tebeľáková, Bašková, 2011, p. 256). According to Rimárová,
(2011, p. 32) the only way to protect the health of patients and to prevent complications is to
comply with the GFD. It is the only causal therapy of CD (Frič, Keil, 2011, p. 357). Samasca
et al. (2014, p. 141) indicate the importance of health education related to GFD at home and
in society, which seems to be the possible solution for improving the QOL of coeliac patients.
The research of Hallert, C. et al. (1998) compared the quality of life of adult coeliac patients
with the general population. Researchers came to a conclusion that even after 10 years of
gluten-free diet, coeliac patients failed to achieve the same degree of subjective health as the
general population, which was particularly true for female coeliacs.
182
In our research, individuals with the CD achieved the mean score 20.87 in SWLS, which
according to Príhodová (2009, p. 105) is the average life satisfaction. Rosinská (2002) states
that the quality life is led by people who are satisfied with their life. Consequently,
satisfaction rate has a very close relationship with a personal understanding of the quality of
life and according to Kožuchová (2014, p. 121), satisfaction rate depends largely on
individual needs, expectations and environment in which an individual lives.
In the dimension of the overall physical health of the SF-36 questionnaire, the coeliac patients
achieved the mean score 58.76. The total score which could be achieved ranged from 31 to
74. In the dimension of the overall mental health, our respondents with the CD attained mean
score of 46.61, while achievable score ranged from 23 to 66. Švihrová et al. (2013, p. 196)
point out to the fact that the CD has a significant impact on the QOL of patients. Based on the
findings of our research, it is clear that the CD has affected the perception of QOL of coeliac
patients. In comparison with the general population, they achieved mean scores in both life
satisfaction and QOL.
Coeliac patients who were not treated for any other serious diseases achieved a higher score
than those who suffered from at least one associated disease (diabetes mellitus, anaemia,
thyroid disease, skin disease, inflammatory bowel disease, etc.) in addition to the coeliac
disease. A moderate statistical significance (p < 0.01) was confirmed in the scale of the life
satisfaction. More significant differences in QOL of coeliacs were observed when other
serious associated diseases were present – in this case, a high statistical significance was
discovered (p < 0.001) in the subscale of physical functioning, role-physical, bodily pain,
general health, social functioning, vitality, mental health, in the dimension of physical and
mental health. Häuser et al. (2007, p. 577) declare that the reduced quality of life in patients
with coeliac disease is associated with physical and psychological co-morbidity as well as
with non-compliance with gluten-free diet. Findings of Neuhausen et al. (2008, p. 160-165)
confirm the increased incidence of autoimmune diseases in families with coeliac disease in
comparison with the general population. Kurppa et al. (2011, p. 87) declare that in many
cases, the subjective perception of health is decreased in untreated coeliacs, the benefit of
GFD treatment bringing better compliance and thus better QOL.
Limitations in the emotional area were demonstrated in our researched group of coeliac
patients as statistically non-significant. Individuals with the CD who were living in a relation
represented 62% of respondents and the remaining 38% did not have a partner. Social and
183
emotional support is an important factor in the disease handling and treatment. A research
conducted in Germany investigated levels of anxiety and depression in women with coeliac
disease who were on gluten-free diet. The results point out to the fact that the adult women
with coeliac disease suffer from higher rates of anxiety than the general population (Häuser et
al., 2010, p. 2780). Addolorato et al. (2004, p. 777-782) examined psychological support as a
factor of the improvement of affective disorders (anxiety and depression). The results show
that psychological support has a positive impact on reducing depression and thus on the
compliance with gluten-free diet. Our findings suggest a sufficient emotional support
provided by partners of people with coeliac disease. On the other hand, the coeliac disease
associated with other diseases proved to be an important factor modifying the quality of life
of individuals.
CONCLUSION
In conclusion, we would like to propose strategies and recommendations based on our
findings. Coeliac care is constantly improving - early diagnosis and gluten-free diet treatment
improve the quality of life of coeliac patients. Thanks to the computer technology, patients are
getting more and more educated, which also helps them to comply with the gluten-free diet.
Coeliac centres play an important role in the improvement of quality of life of affected
individuals, their help being especially important in the period following the diagnosis of the
disease. The centres represent places where coeliac patients find support, understanding and
where new relationships are created, which has a significant psychological effect.
QOL in patients with coeliac disease should be monitored especially due to the changes in the
established way of life in several aspects as a result of the disease, attention being drawn to
the implementation of targeted measures beneficial for these patients. Removing the barriers
from human life requires a comprehensive solution including coordination of activities across
sectors. According to Frič, Nevoral (2009, p. 487), Makovický et al. (2008, p. 17),
Makovický, Rimárová (2008, p. 185) targeted coeliac disease screening could improve
significantly the QOL of coeliac patients. Diminishing of the impact of the chronic disease
can be also achieved by means of self-management, where the risk reduction and
improvement of the results depend not only on the action of healthcare workers, but also on
the action of the patient himself (Nagyová, 2013, p. 192). Health promotion and health
education represent one of the current trends and challenges in the context of nursing care.
184
They also play an irreplaceable role in the provision of services to individuals with coeliac
disease, to their families as well as to the community in hospital and non-hospital sector.
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CONTACT AN AUTHOR
PhDr. Jana Raková, PhD.
Faculty of Medicine, P. J. Šafárik University in Košice, Institute of Nursing
Tr. SNP 1, 040 11 Košice, Slovakia (SK), Europe
E-mail: [email protected]
186
MENTAL WORKLOAD OF THE PARAMEDIC PROFESSION
Sihelská Dana, Šovčíková Eva
Sihelska, D.: Division of Emergency Medicine, Faculty of Health of the Slovak Medical
University in Bratislava located in Banska Bystrica, Sovcikova, E .: Institute of Psychology,
Faculty of Medicine, Slovak Medical University in Bratislava
ABSTRACT
Background: The aim of the study is to determine the most common causes of mental
workload of the paramedic profession (PP). In addition, to assess how paramedics can cope
with the load.
Methods: Set of 214 respondents was evaluated to reach the objective. Chosen sample of PP
working in EMS throughout the Slovakia was in proportion women/men 52:48 ( %). Age
average was 35Y, with a 10.5Y average of practice. Respondents were queried by the
purposefully developed anonymous questionnaire. The questionnaire was designed in nominal
and numeric types of variables to be measureable by the attitudes and opinions of respondents
by Likert-type scale. Statistical analysis was performed by Microsoft Excel spreadsheet and
statistical software Statistica. As a result of the interviews, the frequency and pivot tables
were developed.
Results: The most serious burden of the PP is a meeting the death of a child (88.08 %), the
second place takes the collective accidents and natural disasters (64.76 %), liability (56.19
%), emergency vehicle accidents (53.80 %), insufficient remuneration (53.33 %) and
encountering with the death of an adult (49.04 %). As to the question, how do they cope with
stress, the 25.23 % of respondents pointed out the family support, 23.80 % dealing with stress
by their own, 20.47 % are relying the friendly working environment, 14.28 % needs help of
colleagues. Percentage of 1.42 is seeking for professional help and 0.47 % cannot handle the
stress at all. There are only 0.47 % of respondents who are using the services of a
psychologist at the workplace, 3.80 % from time to time and 43.33 % not at all. Dealing with
similar issues, we compared the results of our research with Seblova et al. (2007, p. 404-417),
Kozena et al. (2006, p. 191-197), Daniel et al. (1984, p. 7-12), Mahony (2001, p. 135-145)
and others.
Conclusion: As the mental workload is the part of PP, it is obvious that mental support is
indispensable. Based on the results of the questionnaire No. 4 it is obvious, that the help of
187
colleagues, clinical psychology and psychiatry services are unavoidable. We recommend to
not underestimate the medical care, to develop the regime work/rest whilst applying a healthy
lifestyle and strong belief in the own personality.
Key Words: mental workload, paramedic, stress, prevention, lifestyle.
INTRODUCTION
Every citizen has the right to a healthy and safe work and quality working environment. This
right allows citizens to live socially and economically in the secure way (Sulcova, 2012, p.
336-346 ).
EUROFOUND carried out The Survey on Working Conditions in the EU in 2005. Research
results have shown that stress is the second most commonly reported issue related to work
activities. The worrying thing is that the stress felt almost every fourth worker. At the same
time the EU studies show that the stress is associated to 50-60 % of all missed working days.
Medical professions like doctors, nurses, paramedics, healthcare providers, physiotherapists,
etc. are professions where mental and physical stress are the significant part of everyday work
which is signed under their health condition and the quality of their work as well.
Experts from different sectors like doctors, psychologists, sociologists, economists, etc. are
more and more busy with impact of stress on health, performance and quality of life of
individuals. They are all trying to get as much information about the problem whilst looking
for solutions contributing to the higher quality of work and life of citizens.
There are many studies in journals and on the internet dealing with stress and burnout. For
example, Duffy, Avalos, Dowling (2014, S1755-599X) conducted research in Ireland for the
detection of secondary traumatic stress in nurses working in the emergency departments.
Froutan, Khankeh, Fallah, Ahmadi, Norouz (2014, S0305-4179) in their research rated the
load of paramedics in treating the affected with burns. Villa, Cruz, Orfila, Creixell, Gonzalez,
Davins (2012, S536-1204) investigated the burnout in teamwork in primary health care in
Spain.
There is a research of mental stress and burnout for paramedic’s profession in the Czech
Republic explored by Seblova et al. (2007, p.404-417). Author Risnovska (2013, p.22-74)
was given to research mental workload for healthcare operators and its relation to selected
personality characteristics.
188
Zidkova et al. (2001, p. 122-126) found out that the majority of physical difficulties of nurses
and healthcare workers are associated with mental stress and burnout. Novotny et al. (2002, p.
3-6) reported that up to 37.40 % of Slovak health workers considered their work as having
failed to excessive mental stress.
Although the mental workload is receiving the increasing attention, despite we’re still finding
out the large deficit in research that would address the issue among the health professionals,
respectively, the paramedics in Slovakia but also abroad. The aim of the study was to
determine the most common causes of mental workload at paramedic profession. In addition,
to assess how paramedics can cope with the load.
METHODS
There are non-standardized items used in the questionnaire to meet the objectives of the
research. This part consisted of 13 items, of which 10 closed and 3 open. We mapped the
degree of the influence of individual Stress factors, at which the paramedic profession is
exposed through. Other items of non-standardized questionnaire observed the relationships in
the workplace, as well as coping with stressful situations and use of balancing strategies. The
last item of the questionnaire is looking at the presence of diseases in rescue team.
In the descriptive part, we obtained data indicated according to the methodology of the
programs Microsoft Excel and Statistica.
For the hypothesis verification purposes, we’ve used the standard statistical methods like
Student's T-test, Paired T-test, ANOVA test and the zero value test of the correlation
coefficient (Rimarcik, 2007, p. 87).
RESULTS
Research involved 214 paramedics, of which 112 women (52 % of respondents) and 102 men
(48 % of respondents). Participants were probands working in the emergency medical service
at the positions doctor/paramedic n = 22 (10 %) and paramedic n = 192 (90 %). The average
age of respondents is 35 years, with an average of 10.5 years of experience. 49.50 % of
respondents reached the bachelor's degree in the emergency medical care and other 2.30 % of
respondents were accredited by the bachelor's degree in another medical area. The doctors of
paramedic fully completed the medical education (10.3 %). Almost all the doctors underwent
the attestation, however in the area of Emergency Medicine it was achieved by 3 respondents
only (ie 1.7 % of the group). The vast majority of the doctors of paramedic have passed an
189
attestation in Internal Medicine and Anaesthesiology and Critical Care Medicine. There were
two doctors (0.9 % of the set) with no attestation completed yet.
The base for the profession of paramedics is the teamwork. We’ve explored how the
paramedic workers evaluate the relationships in their team. Respondents were supposed to
rate their working relationships by the four point scale. It is gratifying that the majority of the
replies were positive.
Table 1 Evaluation of collegial relationships
Collegial Relationships
totally satisfactory
rather satisfactory
rather unsatisfactory
totally unsatisfactory
n
63
125
18
8
%
30
58
8
4
n
52
129
30
3
%
24
60
14
1
Tale 2 Relationship superior – subordinate
Relationship superior - subordinate
totally satisfactory
rather satisfactory
rather unsatisfactory
totally unsatisfactory
Work relations in the both lines, horizontal (Tab 1) and vertical (Tab 2), were evaluated
mostly positive.
Respondents were asked whether and to what extent the nature of the paramedic work is
psychologically burdensome. The majority of respondents considered this kind of work as the
mentally challenging job. Decisive consent was shown at 29 % of respondents, 59 % of them
tended to answer yes and 12 % of respondents considered their job as mentally manageable.
Two respondents disagreed completely.
The third area of our questionnaire focused on the most stressful factors as considered by
approached paramedics. The 5-point scale was available to express through the load (number
1 represented the lowest ranking i.e. absence of the stress in the situation). The highest level
of stress was number 5.
Each of the stress factors were assigned by the basic calculated descriptive characteristics. See
the data in Table 3. Stress factors therein are arranged in ascending order based on the
calculated average.
According to our research, the least stressful factors for paramedics are climate conditions,
lack of amenities at EMS stations, the diversity of the work environment or waiting time for
the intervention. These stress factors were rated below 2.0 in average.
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Table 3 Stress factors
Stress factors
Death of a child
Mass accidents
Liability
Accident of ambulance
Salary
Birth in the ambulance
The death of an adult
Resuscitation
Rescuing the person at accident
Passing the patient to hospital
Feeling threatened
Night shifts
Clients Complaints
Family of the Patient
Lack of information
Poor organization of work
n
154
83
67
65
62
74
67
66
67
59
66
57
62
83
69
59
%
72
39
31
30
29
35
31
27
31
28
27
26
29
39
32
27
AM
4.50
3.83
3.59
3.50
3.48
3.40
3.38
3.17
2.99
2.94
2.87
2.69
2.68
2.57
2.51
2.46
Median
5
4
4
4
4
3
3
3
3
3
3
3
3
2
2
1
Modus
5
5
4
5
5
3
3
3
3
3
3
3
3
2
2
1
SD
0.95
1.22
1.09
1.31
1.30
1.21
1.16
1.26
1.23
1.28
1.16
1.28
1.31
1.02
1.12
1.25
The time pressure, especially when urgent intervention, is common part of the paramedic
profession. We explored how this one is felt subjectively themselves. 30 % of respondents
said they often find themselves pressed for time, 44 % are getting to the time pressure just
partially. The rest of respondents (25 %) do not find themselves in a hurry.
When faced to a stressful situation the distractibility is often as a response. We tried to find
out how intensive the feeling the paramedics can state themselves.
Table 4 Concentration decrease during the stressful event
Concentration decrease during the stressful event
Yes, I do
Partially
Not really
Not at all
n
15
108
67
24
%
7
50
31
11
Most of the respondents experienced the concentration decrease in conflict situations.
We’ve investigated whether respondents would be interested in the Stress Management
Training. 23 % of respondents were clearly pro-oriented. Another 55 % of respondents would
like to attend this kind of courses. 8 % of respondents considered it as irrelevant. The
remaining 14 % of respondents had no clear opinion on this.
The next part of the questionnaire was focused on the tools helping the paramedics to deal
with the stressful situations. We’ve submitted seven possible ways of coping with stress.
People who suffer from long-term stress are losing their sense of control over their own lives.
191
Not to lose control; this means to live a healthy and stress-resistant life, undergo professional
therapies and use relaxation techniques. The section 6 of the questionnaire determined the
procedures used for stress elimination by paramedic personnel.
Table 5 Coping with stress
Coping with stress
Support of close family
By myself/ alone
Creating a suitable environment
Support of colleagues
Ignoring the stress
Professional assistance
Mismanaged the stress
n
111
104
91
64
22
7
2
%
52
49
43
30
10
3
1
n
156
151
61
55
37
%
73
71
26
26
17
Table 6 Stress elimination
Stress elimination
Physical activities
Recreation
Relaxation techniques
Healthy lifestyle
Others
‘Others’ were identified by 17 % of respondents. Most of the paramedics are eliminating the
stress by the contact with family and friends and the labour outside the house. Less suitable
techniques such as smoking or alcohol occurred in few cases.
Confrontation with difficult situations, often under the time pressure, adversely affects the
mental health of a person. Rescuers can handle the stressful situations differently. The most
important factors in coping with stress are general features/ personality, as well as training - a
system of learned procedures to deal with difficult situations. Elimination of the excessive
mental stress can be done with professional assistance of a psychologist. Table 7 provided by
the mapping of utilization the professional assistance.
Table 7 Visiting a psychologist
Visiting a psychologist
Yes, I do
From time to time
Not at all
Others
n
3
15
193
3
%
1
7
90
1
n
3
207
4
%
1
97
2
Table 8 Visiting a psychiatrist
Visiting a psychiatrist
Yes
No
No comment
192
From the data above, it’s obvious, that there are still barriers associated with the visiting a
psychologist. The three respondents (1 %) only do consult with a psychologist on a regular
basis. Another 7 % of respondents are visiting a psychologist occasionally. The majority of
respondents (90 %) do not use the professional assistance of the psychologist at all.
1 % of the respondents had no comment to this question. Even fewer respondents admitted to
the visiting a psychiatrist. Only three of them reported the appointments at psychiatrist, 97 %
of respondents answered negatively and four rescuers (2 %) stated no comment to that
question.
DISCUSSION
88 % of respondents of our research group had identified themselves as a mentally
challenging and facing difficult situations encountered at work having very strong (11 %) to
strong (46 %) intensity. Based on the results of the research it is evident that the most stressful
situation is the death of a child (n = 154, average of 4.50 stress factor), see Table 3, second
one is the mass accidents and natural disasters (n = 83, the average of stress factor is 3.83).
The highly stressful factors of the research group include also: legal liability, accident of
ambulance/ emergency vehicle, insufficient remuneration, birth in the ambulance, the death of
an adult and cardiopulmonary resuscitation (average 3.0 to 4.0). Oglodek and Araszkiewicz
(2011, p. 97) in their study indicated that the most common post-traumatic experience in the
rescue work was physical assault and death of the patient. A similar message was published in
the work of the authors De Soir, Knarren, Zech, Mylly, Kleber and van der Hart (2012, p.
115). When faced with a stressful situation the distractibility is often a response (7 % yes, 50
% partially). Novotny et al. (2002, p. 3-6) points out that up to 37.4 % of Slovak paramedics
consider their work as unsatisfactory as a result of excessive mental stress and 78 % of
respondents believe that their work has a negative impact on their physical and mental health.
Selko (2009, p. 113) is noting that the paramedic profession is carbonated by the stress even
within the optimal conditions. The authors of case study Mazgutova et al. (2012, p. 95-98)
pointed out the significant differences in neuro-psychic stress in the workplace of Palliative
Care, The Internal Department and Intensive Care Unit. The standard deviation and maximum
values pointed out the occurrence of congestion at the surveyed workplaces however the
highest neuro-psychological burden was confirmed at the department of palliative care
(25,282 D and SD 7.552). As mentioned, the base of the paramedics work is a teamwork,
which is ultimately reflected in the success in saving the human lives in the field. 88 % of
193
respondents evaluate the relationships in the horizontal line positively (see Table 1 and 2).
However 12 % of the research group considered collegial relationships as failed, of which 4
% very poor. The vertical line has the similar relationships results (84 %). In the study of
Villa, Cruz, Orfila, Creixell, Gonzalez (2014, p. 568) the results of the research of primary
health care staff focusing on the teamwork and burnout were presented. Almost half of the
respondents (49.20) believe that the teamwork is supported in their working place. Employees
are showing a higher degree of emotional exhaustion (p <0.002) so it’s necessary to look for
the possibilities of burnout protection. Research of Oginski-Bulik (2013, p. 36-54) confirmed
that the support of executives and the teamwork have the positive preventive impact against
the formation of post-traumatic stress disorder.
We surveyed the interest of respondents in the Stress Management Training. 78 % of
respondents welcomed the idea of such a course. 8 % of respondents were negative and 14 %
stated no comment (relatively high percentage for that kind of response). Support of close
family is the most effective factor to cope with stress for the paramedics (52 %), see Table 5,
49 % of respondents balances with stress themselves, 43 % of respondents needed to have an
acceptable working environment created to reach the feeling of psychological well-being and
30 % of respondents are sharing their stressful experiences with colleagues to balance the
stress. 10 % of respondents have chosen solution of ‘exit strategy’ i.e. ignoring the stress.
Professional assistance is sought just by a tiny group of paramedics and just two respondents
(1 %) admitted their failure to cope with stressful situations. 73 % of paramedics are
frequently using method of active recreational activities to relief the stress, passive recreation
is chosen by 71 % of respondents, 29 % of respondents is practising various relaxation
exercises and 26 % of them is keeping the proper diet and healthy lifestyle philosophy. 17 %
of respondents reduces stress by physical activities like the house and garden maintenance
and contact with family and friends. Less suitable techniques such as smoking or alcohol
occurred in few cases. Professional support of psychologist (see Table 7) was adopted just by
very small percentage of respondents (1 %). From the data in Table 7 it is clear that there are
still significant barriers of paramedics to visit a psychologist. Just three respondents (1 %)
from the research group are scheduling consultations with a psychologist on a regular basis.
Another 7 % of respondents are visiting a psychologist occasionally. The vast majority which
is 90 % of respondents do not consider the professional help of psychologist at all. Three
respondents stated ‘no comment’ to that question. Even fewer respondents admitted to the
194
visiting a psychiatrist. Only three rescuers reported the appointments at psychiatrist, 97 % of
respondents answered negatively and four of them did not want to comment this option (Table
8). To promote the mental health of victims and paramedics should be the top priority
according to Takahashi (2011, S224-230). He suggests that all the paramedics, but also other
humanitarian workers should be specially educated and trained to be able to cope with any
stress situation and thus protect their mental health.
The results of the research are based on subjective responses of respondents that may be
affected by the fear of losing the job even while maintaining their anonymity. Therefore, the
respondents failed to always admit their health and mental problems and how they are coping
with it.
CONCLUSION
Significant changes in the performance of work (stress at work, work overload, bullying, etc.),
resulted into the emergence of new psychosocial burdens. Our research aimed to assess the
mental workload at paramedic profession. We found out that 88 % of respondents seen their
profession as mentally challenging and the most stressful factors are the death of a child (n =
154), mass accidents and natural disasters (n = 83), as well as legal liability, accident of the
ambulance, insufficient financial evaluation, birth in the ambulance, the death of an adult and
cardiopulmonary resuscitation. The stress symptoms that occur most often in the paramedic
profession are irritability or explosiveness. Paramedics would appreciate Stress Management
Trainings to learn how to cope with stressful situations (78 %). Support of the close family is
the most common way to eliminate stress at paramedic profession (52 %). Method of active
recreational activities is frequently used by paramedics to relieve the stress however the
professional assistance of psychologist and psychiatrist are adopted just into a very small
extent.
Cope with the psychological load and stress whilst continuing the further work reliably is
sometimes beyond the power and possibilities of the individual. In this point the assistance
should take place to train how to manage the stressful situations. The employer should raise
the attention once the situations like higher rate of absenteeism, fluctuation, frequent conflicts
at workplace or complaints by workers are occurred within the organization.
In terms of the current requirements addressing the mental workload we would like to point
out the issue in the paramedic profession. As the suitable solution for the extreme workload of
195
paramedics, we consider their professional preparation focused on constructive and effective
coping with situations related to mental workload.
In general, the psychological load is often signed under the health issues of paramedics and
other workers in the sector. We do believe that their professional commitment will be
rewarded by the introduction of certain labour benefits, concessions and awards. This could
be transferred to the concrete actions like part time/ shortening the working hours, annual
bonuses, reconditioning, rehabilitation and spa programmes.
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Negative and positive effects of traumatic experiences in a group of emergency service workers, the role of
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NOVOTNÝ, V. et al. 2002. Psychiatric morbidity of the health workers. In
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TAKAHASHI, S.2014 http://www.ncbi.nlm.gov/pubmed/?term=burrnout+among+helth +professionals [Mental
health support for disaster relief personnel].[Podpora duševného
zdravia.pomáhajúceho.personálu.pri.katastrofách]. 21. May 2014.
ONTACT AN AUTHOR
PhDr. Dana Sihelská Faculty of Health SZU in Banská Bystrica
Sládkovičová 21, 974 05 Banská Bystrica SR
e-mail: [email protected]
196
UKRAINIANS IN THE CZECH REPUBLIC AND THEIR KNOWLEDGE
OF FIRST AID
Stelmaščuková Jana, Beharková Natália
Department of Nursing, Faculty of Medicine, Masaryk university, Brno
ABSTRACT
Background: Ukrainians are the most numerous group of foreigners living in the Czech
Republic territory (hereinafter CR). At the labour market they mostly perform physically
demanding, underpaid work, often working longer than the working hours stated by the law.
Not always do they enjoy optimal working conditions as far as hygienic measures and work
safety are concerned. Women find their place in the labour market at services, men work
mostly as builders and auxiliaries in the building industry. The purpose of the survey was to
map the level of knowledge about providing first aid (hereinafter FA) among the Ukrainians
living in the CR and to monitor the influence of the language barrier on communication with
the Integrated Emergency System units. We were also interested in the influence of the
language barrier on the way of acquiring information about the FA procedures, and in the
respondents being interested in further education in this area.
Methods: Quantitative research – a questionnaire survey (Czech questionnaire version n=16
and Ukrainian questionnaire version n=84). The sample – Ukrainians living in the CR
regardless of the stay permit category, older than 18 years of age. 100 completed
questionnaires were analyzed. The survey results and the graphic presentation were processed
by the Statistica 12 CZ software. Graphic presentation of the results was processed by
Microsoft Office Excel and Word 2007.
Results: 15 % respondents subjectively assessed their Czech language level as very good, 41
% indicated the option „good knowledge“. 56 % respondents state they do not feel confident
at telephone calls in Czech or they prefer personal contact. 35 % respondents stated they had
had experience with providing first aid. 48 % respondents consider their knowledge of FA
sufficient and 47 % respondents do not know where to look for information about how to
provide first aid. 52 % respondents declared they were interested in receiving further
education in the FA area, 29 % respondents would undergo such education if it was provided
in the Ukrainian or Russian language. 72 % respondents are interested in receiving printed
materials in the above mentioned languages. A survey of questions testing the knowledge of
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FA: 86 % respondents indicated the free Czech emergency phone numbers correctly, 51 %
indicated the correct scheme of procedure when calling the Health Emergency Service, 73 %
respondents indicated the term “cardiopulmonary resuscitation”, 90 % respondents indicated
the correct reason for starting resuscitation. In total, 64 % knowledge-testing questions related
to providing FA were answered correctly. The best results were achieved by those
respondents who stated they did not know if they had ever provided first aid (n=6; 67,8 %
responses correct) and those who had provided first aid (n=35; 67 % responses correct). As
for age, the most successful were respondents in the age category 18-30 years (n=41; 70,4 %
responses correct), followed by respondents 51 years old (n=9; 63 % responses correct) who
had settled themselves in CR permanently, their knowledge of Czech was good and they
orientated in the Czech environment better. The worst results were achieved by people in the
age category 31-40 years old (n=24; 58,6 % responses correct) and 41-50 years old (n= 26;
59,2 % responses correct). They are people at their working age who, according to statistics
accessed, come to earn money most often and do not intend to settle in the CR permanently.
This is related to their low motivation for mastering the language of the majority, which, at
the same time, limits their access to information.
Conclusion: The survey results imply that the Ukrainians included in our sample have an
approximate idea about first aid procedures but often draw on outdated procedures they
learned long ago. They have gaps in the new recommendations, which could make the
afflicted person's state more complicated or endanger their life. The evidence that especially
the Internet is indicated as the most frequent source of information can be viewed as
important because of the option of using e. g. the pages for foreigners where the information
about FA, the reasons for starting resuscitation, emergency lines and the correct calling
procedure can be posted; information about outdated procedures and myths from the FA area
would not be out of place either. FA information (e. g. orientation in the emergency calls, the
call scheme etc.) could be conveyed within courses preparing foreigners for exams testing
their Czech language knowledge. As for accident prevention, it is important to appeal to a
proper training of all the employees and pay attention to keeping the work-safety regulations.
Key Words: first aid, Ukrainians, accident, knowledge
INTRODUCTION
The number of foreigners living long-term or permanently in the CR increases every year.
Ukrainians are among the most numerous foreign groups living here. Most of them
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concentrate in large urban areas, the reasons being better opportunities at the labour market
and more vacancies. The economically determined immigration often occurs in the form of so
called circular migration. This phenomenon means that especially people at their working age
come to the CR, leaving their relatives in Ukraine. They do not intend to settle in the CR but
they regularly return home with their earnings. Then they repeat these trips according to their
needs. Financial support from the emigrants is often the largest income a family in Ukraine
gets. The work done by the Ukrainians is often underpaid, manual and physically demanding.
It does not usually correspond to the achieved education level. With men it is, above all, hard
or auxiliary manual work in the building industry or industry in general, with women it is
cleaning, working at production lines or as auxiliaries in restaurants. In general, this work is
considered unpromising and unattractive by the Czech citizens. The working hours commonly
are even more than 12 hours a day. They often work in bad or even life-threatening conditions
which can lead to more frequent work accidents. The aim of the survey was to map the
Ukrainians' theoretical knowledge in the area of FA by means of a questionnaire survey. It
was assumed that more than 50 % of knowledge questions would be answered correctly, that
the respondents who have had experience providing FA would achieve better results than
those without such experience and that better results would be achieved by respondents under
30 years of age. Another aim of the survey was to detect the language barrier influence on
communication with the Integrated Emergency System units (hereinafter IES). We assumed
that fewer than 50 % respondents would know the procedure when calling the Health
Emergency Service (hereinafter HES). Another assumption was that more than 25 %
respondents would not feel confident when making a telephone call in Czech or at least prefer
personal contact. A third area of the research was the language barrier influence on acquiring
information about FA procedures. The assumptions were that more than 25 % respondents do
not know where to find information about FA and more than 50 % respondents would
appreciate receiving printed materials on FA in their mother tongue or in Russian and that
more than 25 % respondents do not understand FA information provided in Czech. The last
aim was to find out if the respondents were interested in further FA area education. We
assumed that fewer than 50 % respondents would consider their knowledge of FA sufficient
and more than 50 % respondents would be interested in further FA area education.
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METHODS
To acquire the data necessary for analysis the quantitative method was selected – a
questionnaire survey. The questionnaire was created in the Czech language and expertly
translated into Ukrainian later. 28 questions were construed in total. The questionnaire was
designed for Ukrainians above 18 years of age living in the CR. In the introduction the
respondents were informed about with the purpose of the survey and received completion
instructions. A group of questions followed, asking about the demographic characteristics of
the respondents (namely, the respondents' age, their field of work, sex, length of their stay in
the CR, the subjective assessment of their Czech language knowledge and the ability to lead a
telephone conversation in Czech. Further questions in the questionnaire inquired into the
respondents' experience with providing FA, subjective assessment of their FA knowledge, the
ability to get information about FA, the interest in supplementing their FA knowledge and the
preferred informative language. The theoretical part of the questionnaire included a group of
15 knowledge-testing questions (No. 13 – 27), whose purpose was to verify theoretical
knowledge in the FA area provided to adults. The questions were aimed at the skills of calling
the emergency service, the cardiopulmonary resuscitation and other situations, mainly those
associated with possible work accidents. Question No. 28 mapped the subjective perception of
the questionnaire's difficulty by the survey respondent. In the identification part closed ended
dichotomic questions (No. 3), trichotomic (No. 6, 7, 10 - 12), polytomic (No. 1, 4, 5, 8) and
semi-closed ended questions (No. 2 a 9) were used. In the theoretical part only closed ended
selective trichotomic questions were used with only one existing correct response. The
questionnaire distribution was done in two phases. In the first phase the questionnaires were
placed at two Ukrainian dormitories (Brno - Přízřenice, Modřice) and in the Ukrainian
working team of the Modřice poultry farm. The questionnaire was further distributed among
individuals and to Ukrainian families through whom the questionnaires were spread. The
distributed questionnaires were in both the Czech and the Ukrainian versions. The
respondents could choose for themselves which version they would complete. In the second
phase, with the approval of the Czech Ministry of Interior, Department of Asylum and
Migration Policies, the questionnaire survey was realized at the department of the Czech
Alien Police (the Regional Department for Foreigners' Stays Brno, Brno - Komárov). Only
the Ukrainian version of the questionnaire was distributed there so that the questionnaire
would not be completed by residents of other states. The survey took place from November
2013 till the end of March 2014. 68 (68 %) questionnaires in the Ukrainian version and 16 (16
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%) questionnaires in the Czech version acquired in the first phase were used for analysis as
well as 16 (16 %) questionnaires in the Ukrainian version from the Alien Police department.
The total number of questionnaires fulfilling the analysis conditions was 100 (100 %). The
data acquired from the questionnaire survey was processed by the STATISTICA 12 software,
by Microsoft Office Word and Microsoft Excel. The results are conveyed in tables and graphs
by means of absolute (n) and relative ( %) frequency.
RESULTS
In total, 148 questionnaires were distributed. 98 questionnaires were distributed using selfhelp, including 16 questionnaires in the Czech version, whose return rate was 100 % and all
16 of which were completed correctly. The remaining 82 questionnaires were in the Ukrainian
version with 4 questionnaires not being returned (return rate 95 %) and 10 more having to be
excluded due to incomplete filling of all items. In one case the respondent's age was too low.
50 questionnaires were placed at the Alien Police department where the return rate was 20
questionnaires (40 %), out of which 4 were excluded due to incomplete responses to all
questions. The total return rate for all the distributed questionnaires was 114 (77 %), 14 of
them did not fulfill the conditions for being included in the analysis and were excluded from
the survey. Out of the total number of 100 people taking part in the survey there were 33 (33
%) women and 67 (67 %) men, 41 (41 %) of them being between 18 and 30 years of age, 24
(24 %) people were at the age of 31 to 40 years, 26 (26 %) people were from 41 to 50 years
old and 9 (9 %) were above 50. As for the employment, the largest group were people
working in the building industry - 40 (40 %), then those working in the area of services - 23
(23 %), and students - 18 (18 %). 9 (9 %) people stated other areas, 8 (8 %) respondents stated
being employed in transport and 2 (2 %) respondents stated being employed in health care
(Table 1).
Table 1 Area of work
Area of work
Building industry
Absolute frequency
40
Relative frequency
40,0 %
Services
23
23,0 %
Student
Other
18
9
18,0 %
9,0 %
Transport
8
8,0 %
Health care
TOTAL
2
2,0 %
100
100,0 %
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The most often given response to the question about the length of their stay in the CR was
from 6 to 10 years - 34 (34 %) responses. 33 (33 %) respondents stated the length of their stay
had been under 5 years, 11 - 15 years were stated by 15 (15 %) people, 16 - 20 years by 12
(12 %) people and the least represented group in the survey were people remaining in the CR
for longer than 20 years - 6 (6 %) people. As for the subjective assessment of the Czech
language level, the most frequent response was that the knowledge was good 41 (41 %), the
second most frequent response stated a sufficient level - 35 (35 %), 15 (15 %) respondents
indicated their knowledge as very good and 9 (9 %) state that they consider their knowledge
of Czech insufficient (Table 2).
Table 2 Subjective assessment of the Czech language knowledge
Czech language knowledge
Very good
Good
Sufficient
Insufficient
TOTAL
Absolute frequency
15
41
35
9
100
Relative frequency
15,0 %
41,0 %
35,0 %
9,0 %
100,0 %
The ability of making a phone call in Czech without any problems was stated by 44 (44 %)
respondents, 37 (37 %) respondents can make a phone call in Czech but they prefer personal
contact and 19 (19 %) do not feel confident at a phone call in Czech. The assumed result that
more than 25 % respondents do not feel confident at a Czech phone call or at least prefer
personal contact has been confirmed. As for questions concerning experience, knowledge and
acquiring information in the FA area the respondents stated that 6 (6 %) people had provided
FA so far, 59 (59 %) respondents had never provided FA and 35 (35 %) did not know if they
had ever provided it. 17 (17 %) respondents consider their knowledge of FA sufficient, 31 (31
%) respondents consider them “probably sufficient”, 21 (21 %) respondents think their
knowledge in the FA area is “probably insufficient“, 23 (23 %) respondents stated they did
not have sufficient knowledge of FA and 8 (8 %) were not able to subjectively assess their
knowledge in the FA area. By this data the assumed result has been confirmed – fewer than
50 % respondents consider their knowledge of FA sufficient. 53 (53 %) respondents would
know where to find information related to FA and 47 (47 %) do not know where they would
find this information. Another assumed result has been confirmed here – more than 25 %
respondents do not know where to get the information about FA. Materials about FA in the
Czech language are comprehensible for 57 (57 %) respondents, 14 (14 %) stated they did not
understand the Czech materials and 29 (29 %) stated they had never come across Czech FA
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materials. This data has not confirmed the assumed result that more than 25 % respondents
would not understand FA information in Czech sufficiently (Table 3).
Table 3 Comprehensibility of the Czech materials about FA
Are Czech materials about FA comprehensible
for you?
Yes
No
I don't know, I haven't come across any
TOTAL
Absolute frequency
57
14
29
100
Relative frequency
57,0 %
14,0 %
29,0 %
100,0 %
In those questionnaire items that verified the interest in further education, 52 (52 %)
respondents stated they would be interested in it, even if it was in Czech, 29 (29 %)
respondents would also be interested but only if it was in Ukrainian or Russian and 19 (19 %)
people would not like to improve their knowledge at all (Table 4). The assumed result that
more than 50 % respondents would be interested in further FA education has been thus
confirmed.
Table 4 Being interested in further FA education
Interested in further FA education
Yes
Yes but only in Ukrainian or Russian
Absolute frequency
52
29
19
100
No
TOTAL
Relative frequency
52,0 %
29,0 %
19,0 %
100,0 %
72 (72 %) respondents would be interested in receiving printed materials on first aid in the
Ukrainian or Russian language, 12 (12 %) would not be interested and 16 (16 %) were not
sure. The assumed result that more than 50 % respondents would appreciate receiving printed
FA materials in their mother tongue or in Russian has been confirmed. In the items verifying
the respondents' theoretical knowledge in the FA area 64 % success was achieved (Table 5).
The assumed result that more than 50 % of knowledge-testing questions would be answered
correctly has been confirmed.
Table 5 Knowledge testing questions - assessment
Knowledge testing questions assessment
Correct response
Absolute frequency
Relative frequency
Incorrect response
960
540
64,0 %
36,0 %
TOTAL
1500
100 %
Taking the age into account, the best assessed group of respondents were those between 18
and 30 years of age. Their success rate was 70,4 % (n=41 and 433 correct responses out of
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615 possible ones), which also confirms the assumed result that respondents up to 30 years of
age would achieve better results at the knowledge-testing questions. The second best assessed
group were people above 51 years of age whose success rate was 63 % (n=26 and 85 correct
responses out of 135 possible ones). Respondents aged from 41 to 50 years achieved 59,2 %
success rate (n=26 and 231 correct responses out of 390 possible ones). The worst assessed
group were respondents aged between 31 and 40 years with the success rate of 58,6 % (n=24
and 211 correct responses out of 360 possible ones). The comparison of the knowledgetesting questions' results and the responses touching the FA providing experience did not
confirm the assumed result that the respondents who had had some experience with providing
FA would answer more knowledge-testing questions correctly. The best results were achieved
by those people who stated they did not know if they had ever provided FA to anyone. Their
success rate was 67,8 % (n=6 and 61 correct responses out of 90 possible ones). Respondents
who stated they had had the experience were successful in 67 % cases (n=35 and 352 correct
responses out of 525 possible ones). The people who stated they did not have any experience
with providing FA achieved 61,8 % success rate (n=59 and 547 correct responses out of 885
possible ones). The knowledge of the term “cardiopulmonary resuscitation” was found with
73 (73 %) respondents who gave a correct response. At the item verifying the knowledge of
phone numbers used for emergency calls and the IES in the Czech Republic the respondents
were successful at 86 %. At the item verifying if the respondents knew how to call the HES
they achieved 51 % success. This item did not confirm the assumed result that fewer than 50
% respondents would know the procedure for calling the HES (Table 6).
Table 6 Knowledge-question results: How do you call the HES properly?
How do you call the HES properly?
Correct response
Incorrect response
TOTAL
Absolute frequency
51
49
100
Relative frequency
51,0 %
49,0 %
100,0 %
The best results were achieved by the respondents with the questions asking about: beginning
the cardiac massage (90 % success rate), providing FA to more injured (87 % success rate),
providing FA at sunstroke or calenture (84 % success rate) and providing FA at a fracture of
the leg (83 % success rate). Among the worse assessed questions were those concerning
providing FA at stab wounds where the stabbing object remains in the wound (66 % success
rate), at electrocution (61 % success rate), at burns (60 % success rate), bleeding (55 %
success rate), at the states of shock (54 % success rate), at ingestion of an acid (47 % success
rate), at spinal or spinal cord injuries (42 % success rate) and at ingestion of the antifreeze (22
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% success rate). The last item of the questionnaire was finding out the subjective views of the
questionnaire's difficulty. The most frequent response to the question if the questionnaire had
been difficult for the respondents was „not really“, that is in 46 (46 %) cases, 21 (21 %)
respondents evaluated the questionnaire as difficult, for 15 (15 %) respondents it had not been
difficult and for 11 (11 %) respondents it had been very difficult. 7 (7 %) people were not
able to evaluate the questionnaire's difficulty.
DISCUSSION
The identification part implies that the most frequent participants of the questionnaire survey
were men (67 %) at the age between 18 - 30 years (41 %), working in the building industry
(40 %), who had lived in the Czech Republic no longer than 10 years (67 %). They assess
their knowledge of the Czech language as good (41 %), they can make a phone call in Czech
(44 %), most of them have never provided FA (59 %), still they consider their knowledge of
FA “probably sufficient“ (31 %). They know where they would find information about
providing FA (53 %). The most frequent resource for finding out information about FA was
the Internet (total 35 times out of 71 responses). The FA materials in the Czech language are
comprehensible to the respondents (57 %), the printed materials about FA in Ukrainian or
Russian would be appreciated by 72 % of them. The demographic structure of the respondents
corresponds to the statistical data about the migration of mostly male Ukrainians at their
working age coming to earn money in the Czech Republic, while the work most often done by
them is in the building industry. The other items focusing on assessing the Czech language
level are of purely subjective character and their objectivity cannot be verified, but some
detected contradictions suggest overestimation of the Czech language knowledge level. At the
questionnaire item which verified the subjective perception of the Czech language knowledge
the respondents stated in 91 % cases that their knowledge was at least sufficient but when
assessing their ability of making a phone call in the Czech language only 44 (44 %)
respondents stated this posed no problem to them. The remaining 56 (56 %) respondents have
more or less trouble making a telephone call. A great part of the Ukrainians living in the CR
understand the Czech language but their interpretation of Czech is not good and is hard to
comprehend for the Czechs. It can be stated that the language barrier can have a heavy impact
on communicating with the emergency line operators. In the past, several more questionnaire
surveys were realized, focusing on the FA knowledge among various groups of respondents;
however, according to accessible resources none of them has been focused on foreigners
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living in the CR, therefore an appropriate comparison is hard to find. For the purpose of
mapping the situation in the ability of providing FA it is necessary, therefore, to evaluate the
results of those surveys including varied groups of respondents. To the questions about
assessing the level of knowledge in the FA area in our survey the most frequent response was
„probably sufficient“ (31 %). In Chmelová's survey (2011, p. 57) the most frequent response
is “probably sufficient” knowledge (55,2 %) and in Vránková's work (2013, p. 45) the
respondents most often consider their knowledge good (40 %). When verifying if the
respondents knew where they would find the information about providing FA, 47 %
respondents responded in the negative and 53 % in the positive, compared to Vránková's
survey (2013, p. 46) where only 6,12 % respondents responded in the negative. The most
frequently stated option of looking for information was the Internet and books in both
surveys. The interest in getting more education in the FA area was surprising. Most
respondents (81 %) would be interested in further education and 72 % of them would
appreciate receiving printed materials about first aid procedures in their mother tongue or in
Russian. In Chmelová's survey (2011, p. 59) 71,2 % respondents would be interested in more
education. In Vránková's survey (2013, p. 47) only 26 % were willing to get more education.
Among the questions verifying the knowledge in the first aid area it is appropriate to mention
the results of the item testing the correct procedure when calling the HES. This was answered
correctly only by 51 (51 %) respondents. 33 (33 %) respondents were probably confused by
the telephone number 112, which was offered as an option, which in itself could not be
considered an incorrect response but at the same time there was the incorrect option offered
stating that the caller is the first to finish the call. 16 (16 %) respondents indicated the worst
possible option. They stated they would immediately start providing first aid and would rely
on someone else for calling the emergency, by which procedure they could endanger the life
and health of the afflicted person seriously and prolong the time before they would receive
professional assistance. 90 % of our respondents knew when to start the cardiac massage,
which is the best assessed item of the questionnaire survey and a positive finding. Still, all the
respondents who answered this question correctly cannot be expected to react properly in a
real-life situation requiring an evaluation of the afflicted person's state, possibly followed by
starting the cardiopulmonary resuscitation. The high percentage of correct responses is
probably due to the absence of the option of finding out the pulse; if this had been included,
the number of mistakes would probably have increased. A similar item in Janíčková's work
(2013, p. 38), comparing the pupils in their seventh and ninth grades, was responded to
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correctly by 80 % of the ninth grade pupils and by 90 % pupils of the seventh grade pupils,
which corresponds to our results as well. A large percentage of incorrect responses within our
survey was found at the question verifying the knowledge of FA at massive bleeding. A
correct procedure would only be followed by 55 % respondents, in 6 cases they would apply
just a sterile pressure bandage, which would be hard to find e. g. in the terrain. 39 %
respondents would use a tourniquet to stop massive bleeding whose use is gradually
abandoned and recommended only for use by trained rescue workers or for losses of limbs
and the rules for its use are quite strict. Compared to the results of Vránková (2013, p. 66),
where only 10,2 % respondents would stop bleeding by means of a tourniquet, our result
implies that the Ukrainians are probably not aware of the most recent first aid procedures and
adhere to outdated instructions. The procedure of treating burns was stated correctly by 60 %
of our respondents. 20 % respondents made an error of indicating the option of ripping the
clothes off and cooling the afflicted spot with ice which would have a negative impact on the
afflicted person's state and lead to possible hypothermia. Other 20 % respondents would treat
the burn by applying cream or oil and would puncture the blisters, which again is one of the
outdated or historical procedures endangering the afflicted by developing a secondary
infection at the afflicted part of body. It is interesting to compare this to the diploma thesis of
Nováková (2011, p. 58), comparing the FA knowledge among upper-primary school pupils
and adults. While adults were confident and responded correctly at 93,2 %, primary school
pupils achieved similar results as the Ukrainians in our survey. 51,6 % would proceed
correctly, the rest would either rip off the clothes or puncture the emerging blisters. A very
unexpected finding was at the item verifying the knowledge of FA at electrocution. 61 %
respondents reacted correctly but up to 34 % would move the afflicted on their own from the
place of the accident without making sure that the electric current no longer affects the
person. Considering the fact that most of the respondents work in the building industry this is
a most surprising finding. A similar item in Vránková's survey (2013, p. 64) was answered
correctly by 86 % respondents. In Janíčková's work (2013, p. 40-41) the seventh grade pupils
had the success rate of 70 % and the ninth-graders 90 %, which points out the bad result
among our respondents. A similarly bad result was found at the item verifying the FA
knowledge with suspected spinal or spinal cord injuries. With the percentage of 42 % correct
responses this item is the second worst assessed item in the survey. 26 (26 %) respondents
would not move the afflicted under any conditions which, however, contradicts the priority of
maintaining the vital functions and the person's safety. 32 (32 %) respondents indicated the
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option of laying the afflicted carefully on their back on a hard mat with the help of minimum
two people. Transporting the afflicted with spinal or spinal cord injuries is not recommended
to be done by lay people, any movement of so afflicted is limited only to ensuring the vital
functions and the person's safety. Moreover, two rescuers are not enough for manipulation
with a person so afflicted. Three to five people's participation is recommended to minimize
possible further affliction caused by inexpert manipulation. In Vránková's work (2013, p. 58)
a similar item was answered correctly at 80,61 % and in Chmelová's work (2011, p. 73) even
92 % responses were correct. The item finding out if the respondents could treat the afflicted
person in the state of shock did not bring good results, either. Most injuries or states related to
decompensation of a current illness can lead to a shock, which can also be a symptom of a
newly developed disease. These are acute and life-threatening conditions. We cannot be
satisfied with 54 % success rate of our respondents. The results may be caused by the fact that
a lay person does not often see a person in a state of shock and it is difficult to assess its
presence. Still, when providing first aid even a lay person should have the possible
development of shock in mind and remember at least the rule of the five necessary
precautions. The question is if the Ukrainians know these precautions; the results of the item
in question implies they probably do not. They would in 19 (19 %) cases even underlay the
upper half of the body and would provide the afflicted with drinks and painkillers and in 27
(27 %) cases they would underlay the lower half of the body but would offer drinks as well.
Compared to other works it is obvious that the state of shock and the precautions taken
against it are a problem with all the range of respondents from primary school pupils and
secondary grammar school students, adults and teachers to trained professionals among the
police force and firefighters. In Loubková's survey (2013, p. 62-63) only 53 % police force
and 77,8 % fire brigade members answered a similar item correctly. In Flek's work (2013, p.
43), which mapped the first aid knowledge among secondary grammar school students, 60 %
respondents gave a correct response. The same result - 60 % correct responses was achieved
in Janíčková's work (2013, p. 43), which focused on the knowledge with the seventh and ninth
grade primary school pupils. In Šindelářová's work (2013, p. 51), focusing on the state of first
aid information among nursery school teachers, 78 % respondents responded correctly and in
Vránková's work (2013, p. 67), which surveys the first aid knowledge among parents of
preschoolers, just 15,31 % respondents gave the correct response. Compared to that, in
Chmelová's survey (2011, p. 64-65) a similar item achieved 70,1 % success rate with parents
of lower-primary school pupils. The absolutely worst assessment within our survey belongs to
208
the item finding out the FA procedure at ingestion of an antifreeze. Only 22 (22 %) of the
respondents answered correctly. Fifty (50 %) respondents chose the option of inducing
vomiting and calling the HES. To induce vomiting immediately after ingestion is advisable
but similar to alcohol, the ethylene glycol, which is included in the antifreezes and which
metabolizes within the body into the toxic oxalic acid, is fast absorbed by the mucous
membrane of the stomach. That is why it is advisable to offer an antidote which is pure
alcohol. Fifteen (15 %) respondents would not offer anything and just call the HES, where the
time loss of offering the antidote could be fatal. The lethal dose is 100ml and the pleasant,
sweet taste can lead to drinking a large amount. Among the well assessed items in our survey
are e. g. the knowledge of FA provided at sunstroke or calenture. Both states are caused by
exposing the organism to long-term influence of high temperatures. The results show that
most respondents have come across these states, the success rate at this item was 84 %. In two
(2 %) cases the respondents would cool the afflicted too fast – using an icy bath and in 14 (14
%) cases they would use tepid bath combined with fever remedies. The essential thing at
organism's overheating is gradual cooling, which should not be unpleasant for the afflicted. It
is necessary to prevent the development of hypothermia and to offer drinks and so supplement
the loss of liquid. If we compare the results to Vránková's survey (2013, p. 51), a similar item
was answered correctly by 75,51 % respondents, while in Chmelová's work (2011, p. 68) 79,3
% respondents gave a correct response. The results point out a higher success rate with our
survey respondents. Another relatively well assessed item was the FA knowledge at treating
the open fracture of the leg. 83 (83 %) respondents selected a correct option for the treatment,
3 respondents stated it was necessary to gently push the outreaching bones inside the wound,
which is a gross mistake that would lead to a larger scale injury. Other 14 (14 %) respondents
would apply powder to the outreaching bones to prevent adhesion of the bandage covering the
wound. The procedure stated is incorrect because infection could develop, moreover, with
first aid it is recommended to apply disinfection to the surroundings of any wounds but not
directly in them. If we compare to Nováková's diploma thesis (2011, p. 60), where primary
school pupils achieved 61,5 % success rate at a similar item and adults were correct at 88,3 %,
we can see that the Ukrainians did not have problems with this item and achieved almost
identical results as the Czech adults. According to the results presented above it can be stated
the the FA knowledge with the Ukrainians living in the CR is average or lower average and it
would be advisable to improve it.
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Conclusion: Our survey can be summarized in the following statements: the Ukrainian
respondents have an approximate idea of first aid, however, they often draw on old or
outdated instructions they may have learned at school. There are clear gaps in case of the new
procedures and the Ukrainians would make mistakes providing FA which could lead to
serious complications and more affliction to the injured. In Ukraine the expert medical care is
charged for and so herbs and folk medicine performed mainly by country women. This can be
a partial explanation of the responses concerning the treatment of burns, bleeding, fractures
etc. The interest of the respondents in receiving further education in the FA area is positive
and can be saturated by e. g. organizing a course, creating materials designed for the
Ukrainians, or making use of the web pages for foreigners. The survey clearly implies that the
Ukrainians usually have access to the Internet. Moreover, it would be advisable to expand the
Czech language exam, which has to be passed by each foreigner applying for permanent stay
in the Czech Republic, with questions concerning FA (e. g. the proper procedure when calling
the HES, the emergency lines, etc.)
REFERENCES
BATURKO Z. Integrace Ukrajinců v České republice. [online]. Bakalářská práce. Masarykova Univerzita,
Pedagogická fakulta, Katedra občanské výchovy, Brno, 2012. [vid. 2014-11-8]. Accessible
from: http://is.muni.cz/th/318977/pedf_b/bakalarka_2.pdf
DRBOHLAV D., JÁNSKÁ E., ŠELEPOVÁ P. Ukrajinská komunita v České republice: Výsledky
dotazníkového šetření. In: ŠIŠKOVÁ T. Menšiny a migranti v České republice: my a oni v multikulturní
společnosti 21. století. Vyd. l. Praha: Portál, 2001, s. 96. ISBN 8071786489.
FLEK J. Nástin první pomoci se sondou do znalostí studentů Pedagogické fakulty MU. [online]. Bakalářská
práce. Masarykova Univerzita, Pedagogická fakulta, Katedra fyziky, chemie a odborného vzdělávání. Brno,
2013. [vid. 2014-11-8]. Accessible from:
https://is.muni.cz/th/258960/pedf_b/Nastin_prvni_pomoci_se_sondou_do_znalosti_studentu_pedagogicke_fa
kulty_MU_qhcbdzcu.pdf.
CHMELOVÁ M. Úroveň znalostí v poskytování první pomoci u rodičů dětí mladšího školního věku. [online].
Bakalářská práce. Masarykova Univerzita, Lékařská fakulta, Katedra ošetřovatelství. Brno, 2011. [vid. 201411-8]. Accessible
from: http://is.muni.cz/th/326302/lf_b/Masarykova_univerzita_bakalarska_prace_Chmelova.pdf.
JANÍČKOVÁ D. První pomoc - úroveň znalostí a dovedností žáků 7. a 9. tříd ZŠ. [online]. Bakalářská práce.
Masarykova univerzita, Pedagogická fakulta, katedra speciální pedagogiky.
Brno, 2013. [vid. 2014-11-8]. Accessible from: http://is.muni.cz/th/389115/pedf_b/Bc._Janickova_Dana.pdf
LOUBKOVÁ R. Znalost poskytování první pomoci u příslušníků Hasičského záchranného sboru a Policie ČR.
[online]. Diplomová práce. Masarykova univerzita, Lékařská fakulta, Katedra ošetřovatelství. Brno, 2013.
[vid. 2014-11-8]. Accessible from: http://is.muni.cz/th/326159/lf_m/DP_final.pdf
Ministerstvo práce a sociálních věcí: Kolik cizinců pracuje legálně v ČR? [online]. ČR, 2010 [vid. 2014-05-22].
Accessible from: http://www.mpsv.cz/cs/8487
NOVÁKOVÁ J. Znalosti první pomoci žáků 2. stupně ZŠ a dospělých. [online]. Diplomová práce. Masarykova
univerzita, Pedagogická fakulta, Katedra výchovy ke zdraví.
210
Brno, 2011. [vid. 2014-05-22]. Accessible from:
http://is.muni.cz/th/237452/pedf_m/Prvni_pomoc_Novakova.pdf.
STELMAŠČUKOVÁ J. Ukrajinci v České republice a jejich znalosti v oblasti první pomoci. [online].
Bakalářská práce. Masarykova univerzita, Lékařská fakulta, Katedra ošetřovatelství. Brno, 2014. [vid. 201405-22]. Accessible from: http://is.muni.cz/th/395087/lf_b/BP-_def..pdf
ŠINDELÁŘOVÁ L. Informovanost učitelů o první pomoci v MŠ. [online]. Bakalářská práce. Masarykova
univerzita, Pedagogická fakulta, Katedra výchovy ke zdraví. Brno, 2013. [vid. 2014-05-22]. Accessible
from: http://is.muni.cz/th/386446/pedf_b/Bakalarska_prace-2013.pdf.
TRBOLA R., RÁKOCZYOVÁ M. Vybrané aspekty života cizinců v České republice. [online]. Praha: VÚPS,
2010, s. 123. ISBN 978-80-7416-067-7. 2010 [cit. 2014-05-22]. Accessible from:
http://praha.vupsv.cz/Fulltext/vz_319.pdf
VRÁNKOVÁ V. Znalosti rodičů o poskytování první pomoci dětem předškolního věku. [online]. Bakalářská
práce. Masarykova Univerzita, Lékařská fakulta, Katedra ošetřovatelství.
Brno, 2013. [vid. 2014-11-8]. Accessible from:
http://is.muni.cz/th/366348/lf_b/Znalosti_rodicu_o_poskytovani_prvni_pomoci_detem_predskolniho_veku.p
df.
CONTACT AN AUTOR
Stelmaščuková Jana
e-mail: [email protected]
PhDr. Natália Beharková, Ph.D.
Department of Nursing,
Faculty of Medicine, Masaryk university, Brno
Kamenice 3
625 00 Brno
e-mail: [email protected]
211
THE TOPICS OF BACHEloR THESeS AT THE DEPARTMENT OF
NURSING, FACULTY OF MEDICINE, MASARYK UNIVERSITY
Strakova Jana, Beharkova Natalia
Department of Nursing, Faculty of Medicine, Masaryk University, Brno, the Czech Republic
ABSTRACT
Background: The aim of the investigation was to find out the trends of choosing the topics
for theses at the Nursing Department, Faculty of Medicine, Masaryk University Brno.
Methods: A retrospective study of the online accessible archives of theses was chosen as the
collection method The bachelor degree theses written in the range between 2007 (since the
establishment of the archives) and 2013 were analyzed. The sample of respondents consisted
of nurses, particularly general nursing students of bachelor degree educational program of
both full-time and part-time forms of study. The results of the investigation were processed in
the Statistica 12 CZ. Program.
Results: 374 theses were analyzed. 139 theses (37.16 %) out of this number were focused on
the patients´ awareness and 84 theses (22.46 %) were focused on the patients´ satisfaction.
The respondents addressed within the theses were general nurses (with various degrees of
education and position) in 87 (23.26 %) theses, patients in 110 (29.41 %) theses and general
public in 81 (21.65 %) theses. The questionnaire was the most frequently used method of data
collection (n=336; 89.83 %).A practical output was a part of 59 (15.77 %) analyzed theses.
Conclusion: It results from the investigation that the majority of the respondents are general
nurses and patients and the most frequently chosen method of data collection is a
questionnaire. In the practical outputs, educational materials intended for patients prevail. The
topics of the theses correspond with the recommended trends of nursing research.
Key Words: bachelor thesis, nursing research, nursing, students.
INTRODUCTION
The bachelor thesis on a topic associated with the specialty studied is an integral part of the
final exam of general nursing at the Faculty of Medicine, Masaryk University, Brno. The
theses have a structure ensuring the text to contain all aspects of scientific work. The range
should be 50 pages apart from appendices. The theoretical inputs make up one third of the
212
theses, the remaining two thirds contain the research part. Students are recommended
methodological instructions on how to write bachelor and master theses. .
The first goal of the investigation was to find out what are the trends of the theses. The second
goal was to analyze the data in the dependence on the form of study (full-time study, parttime study). The third goal was to compare the topics of the bachelor theses with the
recommended strategic plan of the National Institute of Nursing Research, USA (2011) and
“The Priorities of the Nursing Research for the 21st Century”, according to ANA – Cabinet
for Nursing Research, In Mastiliaková, 2003.
The analysis of the bachelor theses was based on the criteria assessed: topics, characteristics
of the respondents, investigation methods used and the content of particular practical outputs.
INTRODUCTION The data were collected by means of a retrospective study of the online
accessible archives of theses. The data archived from 2007 to 2013 were analyzed. The
sample consisted of theses written by nurses, particularly by students of general nursing,
bachelor educational program, full-time and combined study. The results of the investigation
are processed in the Statistica 12 CZ program in the form of a description (absolute and
relative frequency). The qualitative analysis of the theses was performed on the basis of
topical orientation, the choice of the respondents, the investigation method used and the form
of the study (full-time study, combined study)
RESULTS
In the period between 2007 and 2013, 374 inputs were analyzed (these outputs were regarded
as 100 % respondents, further called just theses); the theses are stored in the Archives of the
Final Theses of the Masaryk University.
In the whole sample of respondents including both full-time study and part-time study (Goal
2), 139 (37.16 %) , the theses were focused on the patients´ awareness and 84 (22.46 %)
theses were focused on identifying the patients´ satisfaction with, e.g., providing the
information on the intervention. 41 (10,96 %) theses were identifying the nurses´ awareness
of particular diseases, nursing interventions, standard, pain assessment etc.. (the complete list
of the topical focus of the theses is given in Table 1).
The respondents addressed within the bachelor theses were general nurses (with various
degrees of education and working position) in 87 (23.26 %) theses, patients in 110 (29.41 %)
theses and general public in 81 (21.66 %) theses. The questionnaire was the most frequently
213
chosen method of data collection (n=336; 89.83 %). The interview was used in 10 cases (2.67
%), retrospective study of the documentation in 11 cases (2.94 %), 2 observations (0.53 %)
and a combination of research methods were chosen in 14 cases (3.74 %). The practical
output was a part of 59 (15.7 %) analyzed theses; out of this number, 39 outputs were in the
form of educational materials or information leaflets, 18 outputs were intended for the
standardization of nursing care, particularly for the map of the care, nursing care standard,
form for recording the nursing care provided (Goal 1).
Table 1 Topical focus of the bachelor theses
Full-time study
Part-time study
n
60
35
4
26
10
3
12
15
0
2
0
1
168
n
79
49
1
15
16
1
13
13
6
7
1
5
206
Total
%
n
139
84
5
41
26
4
25
28
6
9
1
6
374
%
37.16
22.46
1.33
10.96
6.95
1.07
6.68
7.48
1.60
2.40
0.27
1.60
100
Total
n
87
15
110
81
39
12
%
%
23.26
4.01
29.41
21.66
10.42
3.20
23
7
374
6.14
1.87
100
Topic
Patients´ awareness
Patients´ satisfaction
Quality of life
Identification of nurses´ awareness
Quality of care
Life style
Prevention
Education
Development stage of life
Nursing theories
Nursing education
Aspects of nursing profession
Total
%
35.71
20.83
2.38
15.48
5.95
1.79
7,.4
8.93
0
1,.19
0
0.60
100
%
38.35
2.,79
0.49
7.28
7.77
0.49
6.31
6.31
2.91
3.40
0.49
2.43
100
Table 2 Respondents in bachelor theses
Full-time study
Part-time study
Respondents
n
%
n
%
General nurses
36
21.43
51
24.76
Health care staff*
7
4.17
8
3.88
Patients
51
30.36
59
28.64
General public
35
20.83
46
22.33
Students, pupils
19
11.31
20
9.71
Clients of health care service, social
3
1.78
9
4,.7
facilities
Combination of respondents
13
7.74
10
4.85
Others (diagnostic tests, publications, etc.)
4
2.8
3
1.46
Total
168
100
206
100
*Medical and non-medical health care staff with various education and position
The comparison of bachelor theses with the strategic plan of the National Institute of Nursing
Research, USA a „The Nursing Research Priorities for the 21st Century” ís given in Table 3
(Goal 3).
214
Table 3 Comparison of the topics with the recommended trends of nursing research
Topics
Nursing Department
Patients´ awareness
Patients´ satisfaction
Quality of life
Identification/verification of
nurses´ knowledge
Quality of care
Life style
Prevention
Education
Development life stages
Nursing theories
Nursing education
Aspects of nursing profession
National Institute of Nursing
Research
Health promotion and prevention of
illness
Promotion of the quality of life –
symptomatology and self-care
Dying and palliative care
Innovations
Development of the nursing
research
Priorities for the 21st century
Health promotion, self-care
Prevention of diseases as a result of
the environment and behavior
Reduction of negative effects of
new health care technologies
Ensuring the care of high-risk
groups*
Phenomena of nursing practice
Protection of ethical principles
of nursing research
Development of measuring tools
Development of integrating
methods
Care models
Effectiveness of the learning
approaches
Nursing
*The high-risk groups are represented by the elderly, individuals from minority cultures, children, handicapped
people and poor people
DISCUSSION
The students´ theses have an undisputable importance for nursing research both at theoretical
level and in the application of new findings to practice. At our department, the nursing
research is developed in accordance with the principles of Evidence Based Nursing and
Evidence Based Practice, which corresponds with the necessary demands for nursing research
at universities and all sorts of clinics (Parlour, et al., 2014). Research activities are an integral
part of the profession of general nurses, which is defined in the Czech legislation by the
methodological instructions for the Regulation No. 39/2005:- „Graduates from the Specialty
of General Nursing are, among others, able to perform (or participate in) nursing research and
are able to apply the results of the scientific research to their practice” (methodological
instructions for the Regulation No. . 39/2005 of the Code) The recommendation of the
European Council for the “Strategy of the Development of Nursing Research” represents a
wider legislative scope for the Czech Republic. Apart from other facts, the recommendation
states that the nursing research is a part of nursing and is essential for nursing care providers
and also for those who finance and ensure the education in this specialty.
In our opinion, the topics of the analyzed theses are in accordance with the strategic plan
defined by the National Institute of Nursing Research, USA (2011), and the Priorities of the
215
Nursing Research for the 21st Century according to the committee of the American Nursing
Association (ANA – Cabinet for Nursing Research, In Mastiliaková, 2003).
It results from the qualitative analysis that no significant differences were noticed with regard
to the choice of the topic of the investigation between the respondents of the two types of
study. In the theses, patients were the most frequently addressed subjects. Our results
correspond with the statement by Radková (2012, p. 5) who means that in nursing “the
patients are the main and the most frequent objects of the research, and this relates to their
experience during the nursing process, coping with the disease and the influence of nursing on
experiencing the disease and recovery, and/or experiencing a chronic disease in the wide
range of influences.” From the point of view of topical focus on the form of study (full-time
study or part-time study), the agreement can be particularly seen in the patients´ awareness
and satisfaction. In the full-time study, the theses were also focused on the
identification/verification of the nurses´ knowledge. It can be supposed that this is the result
of topically achieved knowledge and lege artis procedures. In the combined form of study, the
most frequently chosen topics included the topics identifying the quality of care and the
aspects of nursing profession (e.g. the image of nurses in the society, professional role, etc.)
but also the focus on the developmental stage of the individual´s life (e.g. children,
adolescents, the elderly, dying, menopause, etc.).
CONCLUSION
In nursing, it is important for nurses to have knowledge of the research, to take part in the
identification of research problems and to be able to apply the results of the research to their
nursing practice (Farkašová, 2002, Bártlová, Sadílek a Tóthová, 2005). Proposals and
recommendations resulting from the results of individual investigations make up a part a part
of individual investigations. A particular practical output reaching above the scope of
obligatory proposals and recommendations was implemented in 15,77 % theses. There were
no significant differences noticed between full-time study and part-time study, however, it can
be generally stated that questionnaire was the most frequently used investigation form and
patients were the most frequently asked persons. The focus of the theses assessed is in
accordance with both the strategic plan of the National Institute of Nursing Research, USA
(2011), and with the Priorities of Nursing Research for the 21st Century according to the
ANA Committee (ANA – Cabinet for Nursing Research, In Mastiliaková, 2003).
216
REFERENCES
BÁRTLOVÁ, S., SADÍLEK, P., TÓTHOVÁ, V. Výzkum v ošetřovatelství, Brno: NCO NZO, 2005, p. 146.
ISBN 80-7013-416-X.
FARKAŠOVÁ, D. Výzkum v ošetřovatelství. Bratislava: Osveta, 2002, p. 88. ISBN 80-8063-229-4.
MASARYKOVA UNIVERZITA. Archiv závěrečných prací.[online]. 2014 [quatated . 2014-05-22]. Also
accessible from : http://is.muni.cz/thesis/
MASTILIAKOVÁ, D. Úvod do ošetřovatelství. I. díl systémový přístup. 1st edition Praha: Nakladatelství
Karolinum, 2003. 187 s. ISBN 80-246-0429-9
NATIONAL INSTITUTE OF NURSING RESEARCH: Implementing NINR´s Strategic plan: Key Themes.
[online]. 2011 [cit. 2014-05-22]. Also accessible at
http://www.ninr.nih.gov/aboutninr/keythemes#.U5hD63J_tiM
PARLOUR R. et al. Developing Nursing and Midwifery Research Priorities: A Health Service Executive (HSE)
North West Study. Worldviews on Evidence-Based Nursing [online]. [Oxford (UK)]: Wiley-Blackwell
Publishing Ltd., 2014 no. 5. p. 1-9 [cit. 2014-05-22]. Dostupný také z:
http://onlinelibrary.wiley.com/doi/10.1111/wvn.12035/pdf
CONTACT AN AUTHORS
Mgr. Jana Strakova, Ph.D.
LF MU, Katedra ošetřovatelstvi
Kamenice 3, Brno, 625 00
Tel: 549 496 091
e-mail: [email protected]
PhDr. Natalia Beharkova, Ph.D.
LF MU, Katedra ošetřovatelstvi
Kamenice 3, Brno, 625 00
Tel: 549 497 741
e-mail: [email protected]
217
THE OPINIONS OF NURSING STUDENTS ON NANDA – NURSING
DIAGNOSIS
Straková Jana, Saibertová Simona
Katedra ošetřovatelství, Lékařská fakulta, Masarykova univerzita, Brno
ABSTRACT
Background: The aim of this research was to identify and summarize the views of students
of the bachelor´s program in general nursing about the NANDA (North American Nursing
Diagnosis Association) – system of nursing diagnoses and their division into existing
domains. Motivating factor to carry out the research were difficulties that students meet
during the creation of nursing plans for real and fictitious patients and differences they
encounter in practical training in health facilities in comparison with theoretical lessons.
Methods: The technique of in-depth, semi-standardized interview (10 questions).
Respondents were 2nd year (4th semester) full-time students of General Nursing. Obtained
audio recordings were converted into written form and subsequently classified and
categorized by technique of categorization and coding of data.
Results: It was exercised a total of 12 interviews (n = 12, as 100 % of respondents). All
respondents were women, the average age was 21.5 years. In health care, there are currently
working two (16.7 %) respondents. 100 % of respondents expressed a concurring opinion
with the classification of diagnoses in the given domain and completeness of the list of
domains. Formulation of the nursing diagnoses (Czech translation by Kudlová author, 2010)
was highlighted as clear, correct and/or matching by 7 (58.3 %) respondents, 5 (41.7 %)
respondents said that is breakneck formulation, intricately named, or poorly memorable. The
most frequently used diagnoses during creation of nursing plans by students are: acute /
chronic pain, impaired physical mobility, self-care deficit, impaired skin integrity and risk of
infection.
Conclusion: The aim was to identify and summarize the views of students on NANDA
(North American Nursing Diagnosis Association) – system of nursing diagnoses and their
division into existing domains. Data collection was carried out using a semi-standardized
interview with 12 students of the bachelor´s program in general nursing. Respondents´ views
rated positively the organization of system NANDA domains and nursing diagnoses.
218
Conversely, a negative comment was given to wording of the Czech translation (translation
by Kudlová, 2010).
Key Words: NANDA, NANDA domains, nursing diagnoses, students, nursing, opinions.
INTRODUCTION In the Czech Republic providing care through the nursing process is
legally enshrined as the Concept of nursing (The guideline no. 9, Bulletin of the Ministry of
Health, 2004). Thus, future general nurses are familiarized within their qualifying studies with
nursing process in detail and comprehensively. Its second phase is to determine the nursing
problems (nursing diagnoses). Taxonomy of nursing diagnoses has been developed since 80
years by NANDA. The latest versions of NANDA– nursing diagnosis publications is tenth
updated edition, valid for the years 2015-2017. In undergraduate education at universities it is
absolutely necessary to teach students to actively use the NANDA taxonomy. This is a global
system of naming nursing problems (diagnoses) in patients recognized and recommended by
professional community.
The aim of this research was to identify and summarize the views of students of the
bachelor´s program in general nursing on the NANDA taxonomy. Motivating factor to carry
out the research were the difficulties that students meet during the creation of nursing plans
for real and fictitious patients and differences they encounter in the exercise of professional
nursing practice in health facilities compared with theoretical instruction within the qualifying
bachelor's degree.
METHODS
Given the intention to find out the respondent´s opinions, we chose qualitative technique of
depth, semi-standardized interview (range 10 questions) as a method of data collection.
Questions no. 1-3 characterize the respondents (gender, age, secondary medical education and
practice in health care), question no. 4 (first acquaintance with the NANDA taxonomy),
questions no. 5-7, 9, 10 (opinions on the domains of nursing diagnoses) and question no. 8
(the five most commonly used nursing diagnoses). Respondents were students of 2nd year
(4th semester) full-time students of General Nursing. Obtained audio recordings were
converted into written form and subsequently classified and categorized by technique
categorization and coding of data.
219
RESULTS
Basic characteristics of respondents
It was carried out a total of 12 interviews (n = 12, 100 % of respondents). All respondents
were women, the average age was 21.5 years, the youngest was 20 years old, the oldest was
23 years. Previous secondary medical education was stated by 5 (41.7 %) respondents. In
health care, there are currently working two (16.7 %) respondents. 100 % of respondents met
with nursing diagnoses formulated according to the NANDA taxonomy for the first time
during their studies at the university, of which 10 (83.4 %) respondents in the subject of
Theory of Nursing, 1 (8.3 %) respondent in the subject of Nursing Procedures and 1 (8.3 %)
respondent during self-study of scientific literature.
Opinions on the domains of nursing diagnoses
100 % of respondents expressed a concurring opinion with the classification of diagnoses in
the given domain and completeness of the list of domains. They expressed the characteristics
such as "good", "clear", "organized" and "suitable for orientation." The redundancy of
Sexuality and Life Principles domains was commented by 2 (16.6 %) respondents. The
reasoning behind was difficult questioning. Formulation of the nursing diagnoses (mentioned
Czech translation by Kudlová, 2010) was highlighted as clear, correct and/or matching by 7
(58.3 %) respondents, 5 (41.7 %) respondents said that is breakneck formulation, intricately
named, or poorly memorable, eg. nursing diagnosis "Imbalanced Nutrition: Less/More Than
Body Requirements“.
Regarding to a comprehensive evaluation of NANDA taxonomy majority of respondents said
that the benefit of the organization of nursing diagnoses in the NANDA system rests in
working with only one source. Furthermore, allocation according to the domains helps sisters
in specifying the problems of the patient and distribution according to determining features
and related factors assists them to choose nursing diagnosis and appropriate intervention.
Organization of nursing diagnoses has an order and complexity.
3 (25.0 %) respondents mentioned neither the positives nor negatives. However, they would
change nothing in the system. According to their opinion the system describes well the
problems of patients and it is appropriately structured. In contrast, as a negative aspect of the
necessity of formulating nursing diagnoses respondents mostly indicated greater time
allocation when considering which nursing diagnosis is more efficient and accurate for the
220
patient. 2 (16.6 %) respondents also mentioned that the system is sophisticated having a lot of
information and being time-consuming for nurses in the management of records in the nursing
documentation. One respondent stated that she did not understand why care is guided by
nursing diagnoses and it seems unnecessary from her view.
When creating plans for nursing the most frequently used diagnosis by students are: Acute /
Chronic Pain (cited n = 12, ie. 100 % of respondents), Impaired Physical Mobility and SelfCare Deficit reported consistently (n = 11, ie. 91.6 % of respondents), Risk for Infection (n =
8, i.e. 66.6 % of respondents), Impaired Skin Integrity (n = 6, i.e. 50.0 %) and Constipation (n
= 3, i.e. 25.0 %). Other nursing diagnosis mentioned by students are: Imbalanced Nutrition:
Less Than Body Requirements, Noncompliance, Deficient Fluid Volume, Diarrhea, Activity
Intolerance, Risk for Falls, Impaired Comfort, Fatigue, Impaired Gas Exchange and nursing
diagnosis of Elimination and Exchange domain.
Asked about utilization of nursing diagnoses in practice, 100 % of respondents replied that,
nursing diagnosis are usable in practice and they have a contribution to improving the quality
of care provided. On the other hand, the view was also expressed that it always depends on
the specifics of the department and it would be better to have prepared the structure of the
most frequent nursing diagnoses instead of full overview of NANDA taxonomy.
DISCUSSION
The research was mostly attended by students without prior medical education and experience
in the field. Secondary medical education was reported by 41.7 % of respondents while only
16.7 % of respondents are now working in clinical practice (1x carer, 1x medical assistant).
Therefore, it allows us to argue that the respondents' views are only shaped by theoretical
lessons within undergraduate Bachelor's degree and by practical experience gained mainly
during school nursing practice (100 % of respondents meet for the first time with the NANDA
taxonomy during their college studies).
Obtained knowledge of students shows that the organization and sorting of nursing diagnoses
into domains suits students. The redundancy of Sexuality and Life Principles domains was
expressed by 16.6 % of respondents. Given rationale which is difficult questioning, however,
tends to indicate a lack of communication skills.
Respondents also expressed their difficulties in using NANDA taxonomy (negative evaluation
of the specific formulations / wording of diagnoses reported by 41.7 % of respondents) during
221
theoretical lessons as well as in the environment of clinical workplaces. This evaluation is
logical to given fact that those are students with limited practical experience. Other aspects of
considered verbal formulations are different sociocultural environment in the USA, where
NANDA taxonomy was created, and the actual Czech translation. Translation is always a
compromise between preserving the meaning and stylistic purity of translated text. Patient
care through the nursing process including NANDA taxonomy, NIC and NOC is standard and
integral part of the curriculum of university-educated nurses. The necessity of comprehensive
nursing teaching plans on the basis of NANDA, consistency in teaching of theoretical and
practical subjects and areas that make trouble for students is pronounced by other authors, eg.
Smith and Craft-Rosenberg, 2010 in his paper titled Using NANDA, NIC and NOC in an Ungraduate Nursing Practicum.
Difficulties of students with using NANDA taxonomy can be reduced in multiple ways. As an
example, we introduce OPT model (Outcome-Present State Test) testing the ability of
students to work with all components of the alliance NNN (NANDA, NIC, NOC), (Kautz et
al., 2006). Furthermore, it can be a software support, eg. program of HANDS - Hands on
Automated Nursing data System developed by the College of Nursing, The University of
Iowa (Smith et al., 2010). Last but not least, these difficulties might be reduced by lessons
given by qualified experts.
Time requirement and complexity of the system was stated by 16.6 % of respondents as a
negative of the use of already formulated NANDA taxonomy. We believe that after
acquisition of practice the whole process will become less time consuming for students.
Already formulated taxonomy has an advantage in just choosing of diagnose from the
complete list. In an environment of clinical practice nurses are helped in developing nursing
plans mainly by digital nursing documentation and sample designs of nursing plans for
patients with specific diseases.
CONCLUSION
The aim of this research was to identify and summarize the views of students on the NANDA
taxonomy, in particular the distribution of nursing diagnoses into existing domains and their
actual wording. Respondents rated positively the organization of NANDA taxonomy to
domains and integration of nursing diagnoses. Conversely, a negative comment was given to
wording of the Czech translation (students are widely met with translation by KUDLOVÁ
author, 2010).
222
REFERENCES
GREEN J, THOROGOOD N. Qualitative Methods for Health Research. 2nd edition. London: Sage Publications
Ltd, 2011. 304 p. ISBN 978-1-84787-073-2
KAUTZ D, KUIPER R., PESUT D., WILLIAMS, R. Using NANDA, NIC, and NOC (NNN) Language for
Clinical Reasoning With the Outcome-Present State Test (OPT) Model. International Journal of Nursing
terminologies and Classifications [online]. [Philadelphia, US]: NANDA International, 2006, vol. 17, no 3, p.
129-138 [cit. 2014-08-11]. Dostupné z: http://onlinelibrary.wiley.com/doi/10.1111/j.1744618X.2006.00033.x/pdf
MINISTERSTVO ZDRAVOTNICTVÍ ČR. Koncepce ošetřovatelství. Metodické opatření č. 9. 2004. 32 p.
NANDA INTERNATIONAL. Nursing diagnoses. Definitions and Clasification 2009-2011. 8th edition. Oxford:
Wiley-Blackwell, 2009. 435 p. ISBN 978-80-1-4051-8718-3
NANDA INTERNATIONAL. Ošetřovatelské diagnózy. Definice a klasifikace 2009-2011. Překlad Kudlová.
Praha: Grada Publishing, 2010. 456 p. ISBN 978-80-247-3423-1
SMITH K., CRAFT-ROSENBERG M. Using NANDA, NIC and NOC in an Ungraduate Nursing Practicum.
Nurse Educator. 2010, vol. 35, no 4, pp 162-166. ISSN 0363-3624
ŽIAKOVÁ K. a kol. Ošetrovatel'stvo teória a vedecký výskum. 2. vyd. Martin: Osveta, 2009 323 p. ISBN 808063-304-2
CONTACT AN AUTHOR
Mgr. Jana Straková, Ph.D.
LF MU, Katedra ošetřovatelství
Kamenice 3, Brno, 625 00
Tel: 549 496 091
e-mail: [email protected]
Mgr. Simona Saibertová
LF MU, Katedra ošetřovatelství
Kamenice 3, Brno, 625 00
Tel: 549 496 091
e-mail: [email protected]
223
IMPLEMETATION OF SEPSIS PREVETION GUIDLINES FOR
NURSES INTO A CLINICAL PRACTICE
Streitová Dana, Zoubková Renáta, Vavrošová Jana
Facultas Medicinae, Department intensive medicine and Forensis studies, Clinic of
Anestesiology, resuscitation and Intensive Medicinae, Universitas Ostraviensis
ABSTRACT
Background: Sepsis is one of the most serious complications in intensive care patients, which
is associated with high mortality and morbidity of critically ill patients. Measures based on
the effective prevention are one of the main strategies of treating patients. Aseptic procedures,
barrier nursing techniques, selection of equipment used for the treatment as well as the
replacement frequency of protective barriers are preferred nursing interventions of sepsis with
regard to the prevention. The objective of this retrospective study was to assess the
importance of nursing interventions and aspects of the incidence of sepsis and infectious
complications in ICU patients, including analysis of erroneous nursing procedures that could
affect the formation of sepsis.
Methods: A retrospective study was conducted by data collection from medical records
and observation of patients hospitalized at the Clinic of Anesthesiology and Intensive-care
during the period from January 2009 to December 2012. The overall sample consisted of 736
patients who were diagnosed with sepsis by a doctor according to confirmed infectious
etiology. Data were processed by descriptive statistics, frequency tables and x2 (chi-square)
test were used for evaluating and the Fisher's exact test was used for small frequency (n <5).
Statistical tests were assessed at the significance level of 5. There were identified 231 patients
with sepsis, 106 patients with confirmed infectious etiology, 31 patients with confirmed noninfectious causes (SIRS) and 7 cases of other infectious cause was confirmed during
hospitalization. Another category of patients was represented by cases, in which the positive
sputum was found in injection site infection, in positive punctate in wound, in purulent
secretion from the wound or bacterial findings in urine without general symptoms of
infection. Nursing interventions were analyzed with regard to the prevention of sepsis patients
in intensive care.
Results: The largest number of sepsis was proved in 2009 (26.23 %) and in 2010 (20.01 %),
while in 2011 (11.67 %) and 2012 (14.02 %) there was recognized a decrease in sepsis.
224
According to the etiology there was significant share of VAP and catheter sepsis compared to
uremic and early infection Out of the nursing procedures that have proven to be important for
the prevention of VAP there were identified a closed suction method, the selection of the
endotracheal tube, the use of semi recumbent position. Selection of the catheter, puncture site
selection, use of infusion filters or disinfection options were found as important examples in
the prevention of catheter sepsis. Using a closed circuit system has proved to be the most
effective in urinary tract infections. The results clearly show the effect of educational
activities of working group on compliance with the rules of asepsis, compliance with barrier
nursing activities and practices that are entirely in the hands of the nursing staff.
Conclusions: All preventive measures are in accordance with the recommendations of CDC
(The Centers for Disease Control and Prevention) and SHEA (The Society for Healthcare
Epidemiology of America) that recommend the education and training of the staff. The
objective is to increase awareness of the necessity of preventive measures which help to
reduce the incidence of infection with subsequent sepsis in patients in intensive care. Regular
education and practical training can not only improve the quality of care, but we can also
implement new procedures into the practice with regard to the nursing staff awareness of the
importance of sepsis prevention at intensive care units.
Key Words: sepsis, preventive measures, ventilator-associated pneumonia, urinary tract
infection, catheter sepsis.
INTRODUCTION
Sepsis is a complex syndrome that is difficult to define, diagnose, treat and care for. It is a
series of events and changes in the body caused by the overall body's response to infection. Its
annual incidence is according to available literature of approximately 3 cases per 1,000
inhabitants - Worldwide over 18 million cases. It is also expected annual increase of 1.5 %.
The overall number of deaths increases every year. Literary sources (Kula, 2004) reported
350,000 deaths per year (USA and Europe), the medical costs of almost € 26 billion, and
limited effective diagnostic and therapeutic interventions. At present greatest emphasis is
placed on the use of methods which are able to reduce the risk of sepsis development. Nursing
procedures preventing infection transition are among the practices that significantly contribute
to reducing the incidence of sepsis. Given the high mortality rate for severe sepsis, the center
of attention of professional associations became procedures that could be used to influence
the negative numbers of dying of sepsis and septic shock. An international group of experts
225
engaged in intensive care and infectious diseases has therefore established a standard of care
for patients with severe sepsis, which are summarized in the Barcelona Declaration. In
accordance with the activities of medical society there was established Forum for Sepsis in
April 2005. The main objective of Working Group for the Prevention of Sepsis in intensive
and resuscitation departments in the University Hospital Ostrava is the education of the
nursing staff about the need to respect all the principles concerning implementation of nursing
interventions with regard to the risk of infection development. It was created educational
program (http://sepse.fnspo.cz), which was also implemented in the curricula of students in
higher vocational school of health and Faculty of Health and Social Sciences. There were
conducted studies that showed the need for continued educational and preventive activities in
terms of sepsis prevention. Nursing procedures that prevent infections are among the
procedures which significantly contribute to reduction of incidence of sepsis. It is problematic
staff awareness of the importance of hand washing, lack of compliance with the rules of
sterility in introducing intravenous catheters or for example the predominance of the supine
position in mechanically ventilated patients or the use of the incorrect technique of secret
suctioning. The problem is ignorance in compliance with the rules for the proper use of
protective equipment, compliance with barrier nursing techniques, proper wound care and
other preventive measures that relate to the prevention of hospital infections. A number of
studies indicate that unused space for introducing these simple and cost-efficient procedures
into everyday clinical practice actually exists. Infections mean a huge risk to patients and
medical staff, so that every step in the process of infection prevention is important. The
objective of this retrospective study was to evaluate the level of importance of specific
nursing interventions on the incidence of sepsis in patients hospitalized in KARIM FHO. The
aim was to detect erroneous nursing procedures that could influence the formation of sepsis. It
was also necessary to assess whether the impact of these practices and using specific tools, its
proper use, selection of materials and compliance with recommended replacement could
affect the occurrence of certain types of infections, including sepsis. The assessment of
procedures implemented in the treatment of patients with sepsis has been taken on the basis of
educational activities on the prevention of sepsis in intensive care in FHO. Activities of The
working groups on the prevention of sepsis in intensive care FHO started in April 2005.
The main task of the working group was to establish educational activities of medical staff in
intensive care and develop materials for the preparation of standard operating procedures for
the various practices related to the prevention of sepsis at intensive care units.
226
Determining hypotheses
H01 I assume that the educational activities of the working groups for the prevention of sepsis
are related with a lower incidence of sepsis in patients admitted to the ARC FHO.
H 02 I suppose that the most common cause of sepsis in patients admitted to the ARC FHO is
ventilator-associated pneumonia (VAP).
H
03
I assume that the introduction of optimal preventive measures within the context of
nursing procedures and interventions may influence the frequency of sepsis in patients
admitted to the ARC FHO.
H
04
I suppose that the erroneous intervention in treating patients with artificial lung
ventilation (UPV) is an open method of suction of the respiratory tract.
H 05 I suppose that the erroneous intervention in the treatment of patients with central lines
include non-use of barrier protection measures in the infusion line.
H
06
I suppose that the erroneous intervention in the treatment of patients with established
urinary catheter include non-adequate replacement frequency of urinary catheter.
METHODS
During the 12 months (January-December 2013), we collected data from medical records of
patients hospitalized at KARIM FN Ostrava during the four- year period from January 2009
to December 2012. The overall sample consisted of 736 patients, of whom 231 (31.39 %)
patients were diagnosed with sepsis. In 106 cases sepsis originated and infectious etiology
was confirmed during hospitalization. Criteria for inclusion in the study was abnormal body
temperature> 38 ° C or <36 ° C, abnormal heart rate> 90/min (otherwise unexplained),
abnormal respiratory rate> 20/min. or paCO2 <4.3 kPa (otherwise unexplained), abnormal
leukocyte count> 12 x 109 / l or present leukopenia <4 x 109 / l, the presence or the premise
of infection, positive blood culture findings and a final diagnosis of doctor. Data were
obtained by questionnaire survey. It was created the form for data collection containing 122
items. The first part focuses on the characteristics of the sample, length of stay, type of sepsis,
the emergence of sepsis during hospitalization, infectious agents and the final confirmation of
the diagnosis of sepsis by doctor. The remaining four sections of the questionnaire evaluate
the resulting types of sepsis (VAP, catheter, uremic and early sepsis), the use of specific
equipment and nursing procedures that were applied in selected patients. Data obtained by
227
questionnaire survey was first processed by descriptive statistics. For the evaluation of the
data were used frequency tables and x2 (chi-square) test, in case of small frequency (n <5)
Fisher's exact test. Statistical tests were assessed at the significance level of 5 %.
RESULTS
In 2009, originated 26.23 % of septic states and in 2010 the number was 20.01 %. In 2011 it
dropped to 11.67 % and in 2012 the data were nearly the same - 14.02 %. In accordance with
the activities of Working Group on the Prevention of Sepsis, which started its activity in
2005, since 2010 in FHO we organized regular seminars with selected issues concerning
prevention of sepsis from the perspective of the nursing staff on a month bases. Based on that
information there were created standard operating procedures that were evaluated by audit.
All the preventive measures that have been established thanks to the working group are in
compliance with the recommendations of CDC (The Centers for Disease Control and
Prevention) and SHEA - The Society for Healthcare Epidemiology of America). Based on
these data, we can observe the loss of sepsis among the group of respondents. According to
infectious etiology there was recorded ventilator-associated pneumonia in 39 (36.80 %) and in
an additional 20 (5.34 %) patients were recorded infections of the upper and lower airways in
the results of the reference group of respondents. These were mainly community-acquired
pneumonia, which did not occur in connection with artificial ventilation. Catheter sepsis was
also confirmed in 39 (36.80 %) cases, early infection in 23 (21.70 %) and uremic sepsis in 5
(4.7 %) cases.
DISCUSSION
It turns out that the number of VAP (39) and catheter sepsis (39) is represented in the same
number as compared with the occurrence of uremic and early infections, which are
significantly higher. The influence of these infections depends on the number of ventilated
patients (375) and especially the number of patients with established vascular catheter (617).
Catheter infections and ventilator-associated pneumonia are very frequent complications in
ICU units. Prevalence Study (ŠRÁMOVÁ et al., 2009) shows that the largest proportion of
infections are pneumonia and lower respiratory tract infections (47.5 %), bloodstream
infection was diagnosed in 14.2 %, 18.3 % urinary infections and surgical wound in 6.9 % of
total number of infections (493). Our sample file therefore contains 59 (42.14 %) pneumonia
cases, which is almost comparable with the study of ŠRÁMOVÁ (2009). It is one of the most
common infections according to The European Prevalence of Infection in Intensive Care
228
study (EPIC) and it represents 45 % of all infections in the ICU VAP. Authors Chytra et al.
(2003) suggest that the incidence of VAP ranges from 8-28 %, which is in contradiction with
the findings in the study of ŠRÁMOVÁ (33.9 %) and the reference group of respondents
(36.80 %). In the case of catheter infections, most studies agree on the incidence of 3-12 %.
The study of ŠRÁMOVÁ (2009) confirmed the number 14.2 %. Ševčík in his lecture notes
from a source of CDC (2002), the incidence of 15-25 %. Hugonnet et al. (2004) reported
incidence of 19.8 %. In a retrospective study there is the result of 39 bacteriologically
confirmed catheter sepsis for a period of 4 years, the equivalent of one year is about 5.31 %.
This result corresponds to the above studies.
In case of early infection the incidence in clean wound ranges usually between 2-5 % of all
infections. The same number is listed by SHEA (The Society for Healthcare Epidemiology of
America). The study confirmed the results for four years at 21.70 %. Converted into one year
it is 3.1 %, which confirms the above data. In uremic infections the incidence is around 17 %.
It is the second most common cause of secondary bacteremia, following catheter infections.
ŠRÁMOVÁ study (2009) showed that the incidence varied between 18.3 %. In the study of
the Regional Office of Public Health (RÚVZ) in Trnava (2007), the number ranged in 26.0 %.
In monitored set of respondents resulting data showed the incidence of urinary tract infections
in the number of 4.7 %. Practical measures, which aim to highlight practical preparedness of
staff working in intensive beds to reduce infections and sepsis, are part of the measures
recommended by companies like SHEA - Society for Healthcare Epidemiology of America.
In the context of first recommendation it is all about compliance with semi recumbent
position, use of intubation cannula with suction of sub glottal space and pressure maintenance
in the cuff, preventing unplanned extubation and reintubation. The second recommendation is
especially important to ensure the decolonization of the oropharynx and perfect, regular oral
hygiene. The third strategy is to care for the ventilation equipment such as circuits, nebulizers,
etc. The use of the supine position in mechanically ventilated patients represents independent
risk factor for the development of pneumonia associated with artificial ventilation. The
probability of its occurrence in supine position is almost three times higher and it is probably
a consequence of the higher risk of gastro esophageal reflux, microbially contaminated
content and subsequent aspiration. Semi-recumbent position, when the axis of the chest forms
with the axis of pad an angle > 30º is considered to be effective prevention of gastro
esophageal reflux and subsequent aspiration. Torres et al. more than ten years ago found that
the supine position is connected with bacterial findings in the stomach and endobronchial
229
findings up to 70 % of cases with positive endobronchial cultivation. In a prospective
randomized clinical study, which objective was to analyze the relationship between the supine
and semi recumbent position and occurrence of VAP, Drakulovic et al. discovered 80 %
lower incidence of microbiologically confirmed VAP in patients in semi recumbent position.
On the contrary to the above findings there is surprisingly low use of this method in clinical
practice. At random monitoring in the group of 170 patients Grap et al. found 70 % incidence
of supine position and the average value of the elevation of the torso only 19 º. Cook DJ., Et
al. dealt with the analysis of the causes of this situation, concluding that the main problem is
the low level of nursing staff awareness of the importance of semi recumbent position. In the
study group of respondents there was compared the influence of positioning the patient into a
semi recumbent position and the incidence of VAP. Statistical difference in investigated
samples was p <0.001, which undoubtedly confirms the importance of the elevated position of
patients. Additional monitored intervention from the nursing perspective was the method of
suction. Chytra (2009) in his work quotes Siempos Br. J. Anaesth (2008), who state that the
difference between open and closed method has not been proved and there is only difference
in economic profitability. In the investigated group of respondents, we evaluated 329 cases of
suctioning, where we found a total of 71 positive cultures of sputum collected and 258
negative cultures and we found a statistical difference p <0.001. In the open method of
suction, there were 64.78 % of positive findings and in closed method with only 35.21 %
positive cultures. Authors (Ibrahim EH, et al., 2008) published information about the
importance of use of cannulas with the possibility of suction sub glottal space. In 337 patients,
we evaluated the bacteriological sputum culture. In cases where we used cannula with the
suction, we found positive rate in 16.30 %. In contrast, when using conventional cannula we
discovered positive rate in 25.71 % cases. Furthermore, we evaluated the length of the
endotracheal or tracheostomy cannula and its impact on the incidence of positive sputum. The
biggest positivity was found in the case of dwelling cannula longer than 14 days (41.18 %).
The problem of introducing is related to attachment of the biofilm, which is itself a risk factor
for VAP. Ideal cannula could possibly be coated with the silver ions, which are mentioned in
his lecture Chytra (2009). He cites here multicenter prospective study of Kollef, JAMA
(2008), which states that the use of these cannulas reduces the number of VAP by 35 %. A
very important recommendation is to decolonize oropharynx. There are studies that evaluated
the effects of the use of chlorhexidine, which was used for the decolonization of the oral
cavity. In a study SCANNAPIECO (2009) when using 0.12 % chlorhexidine they failed to
230
reduce potential pathogens in dental plaque and the occurrence of VAP. These were patients
at traumatological or mixed ICU. Conversely, a reduction in incidence has been demonstrated
with the use of less concentrated 0.12 % chlorhexidine in patients on Cardiology ICU.
Another randomized study Panchabhai (2009) notes the importance in the use of 2 %
chlorhexidine in 12 - hour treatment of the oral cavity. The authors consider that the more
concentrated solution has a lasting impact on reducing the formation of plaque (biofilm).
Studies suggest that further research surveys should be implemented when using a more
concentrated solution of chlorhexidine (2 %). On the issue of catheter sepsis prevention are
defined specific recommendations. This is essentially the method of selecting the insertion
site, choosing the type of catheters, skin disinfection, method of treatment of inputs,
protection of the infusion lines, etc. The greatest recommendation by SHEA is education and
training of the staff involved in the introduction and treatment of catheters. In addition at strict
hand hygiene, sterile barrier, injection site disinfection with chlorhexidine and selection of the
insertion site. In reference file we studied the influence of line filters to infection. Patients
who had the infusion line protected by line-filter had a positive culture at 13.40 %, while
those, who had no filter at 30.15 %.
In recommendations there is often a reference to the choice of catheters, which are protected
by coating of mixture of antibiotics, silver ions, chlorhexidine or positive membrane. The
principle of all is the elimination of biofilm inside a catheter and subsequent colonization of
the lumen. In set of observed respondents, we compared the effect of catheters coated with the
chlorhexidine / silver sulfadiazine effect with the conventional catheter. The catheter was
coated only inside lumen. The result showed that the use of antimicrobial coated catheter was
positive in cultures at 6.58 %, and when using a conventional catheter that was at 37.25 %.
Statistically significant difference was (p <0.001). The same experience published authors
Maki et. al (1997) who state that the use of antibacterial catheter colonization decreased from
24.1 % to 13.5 % and there was a decrease of catheter infection of 7.6 / 1,000 days to 1.6 /
1,000 days. In another study Jager et al. (2002) states that catheters with a mixture of
chlorhexidine / silver sulfadiazine were used in cancer patients receiving chemotherapy. An
important and recommended element of prevention is thorough preparation of the insertion
site and especially its disinfection. The study recommends disinfection with 2 % aqueous
solution of chlorhexidine gluconate. In the study group of respondents there was used
magistralite chlorhexidine solution. We found positive rate in 12.70 % when using an
alcoholic solution in 17.63 % and an iodine solution in 31.67 %. A statistically significant
231
difference (p> 0.001). With regard to the urinal infection prevention it is recommended in
accordance with the methodology of Evidence Based Medicine Group and the maintenance of
a closed urinary drainage. In the study group of respondents, there was used a closed system
in 496 patients and a positive rate of bacteriological examination of urine was found in 16.13
%. In 15 patients a closed circuit was not used and the positive cultures occurred in 46.67 %
of cases. Statistically significant difference p> 0.002 confirmed the influence of the closed
drainage to reduce urinary tract infections. Furthermore, there was evaluated the length of the
introduction of urinary catheter in connection with the occurrence of urinary tract infection.
From the file of 518 drained patients, there was found that when replacing the catheter to 7
days there was 0.51 % Urinal infections. In the category of catheter introduced to 14 days,
there were confirmed positive cultures in urine at 2.61 % for urinary catheters introduced
more than 14 days positivity was found in 21.43 %. Statistically significant difference p
<0.001 confirmed a significant correlation between the observed factors.
CONCLUSION
Intensive education and participation of nursing staff in implementing preventive measures
affecting the incidence of sepsis and infectious complications in the workplace of intensive
care, focusing particularly at treatment of critically ill, can reduce the incidence of infectious
complications and sepsis cases in intensive care. It is necessary to include preventive
measures affecting incidence of septic complications in intensive care nursing and therapeutic
protocols.
REFERENCES
KLEINPELL,R., et.al. 2013. Implications of the New International Sepsis Guidelines for Nursing Care
Published. Online http://www.ajcconline.org© 2013 American Association of Critical-Care Nurses Am J Crit
Care 2013;22:212-222 doi: 10.4037/ajcc2013158
ALBERTI, C. et al. 2002. Epidemiology of sepsis and infection in ICU Patients from an International
Multicenter Cohort Study. In Intensive Care Medicine. ISSN 0342-4642, 2002, vol. 28, no. 4, p. 525-526.
AMERICAN THORACIC SOCIETY&IDSA. 2005. Guidelines for the management of adults with Hospitalacquired,Ventilator-associated, and Healthcare-associated Pneumonia. In American Journal of respiratory
and Critical Care Medicine. ISSN 0090-3493, 2005, vol. 171, pp. 388-416.
CHASTRE, J. - FAGON, J. Y. 2002. Ventilator-associated pneumonia – State of the Art. Am. j. Respir. In
Critical Care Medicine, ISSN 0090-3493, 2002, vol. 165, pp. 867-903.
IBRAHIM E. H., et al. 2001. The occurrence of ventilator-associated pneumonia in
a community hospital: Risk factors and clinical outcomes. In Chest. In Chest. ISSN
0012-3692, 2001 Aug. Vol. 120, no. 2, pp555-561.
KULA, R. 2004. Těžká sepse – lze jí předejít? In: Postgraduální medicína. ISSN 1212 – 4184, 2004, květen, č.
6, s. 616 – 621.
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MAĎAR, R. - PODSTATOVÁ, R. 2006. Prevence nozokomiálních nákaz v klinické praxi. 1.vyd. Praha: Grada,
2006. s. 180. ISBN 80-247-1673-9.
MAKI, et.al. 1997. Prevention of Central Venous Catheter-Related Bloodstream
Infection by Use of an Antiseptic-Impregnated Catheter .Univercity of Wisconcin.
In Annals of Intemal, ISSN 0003-4819. August 15,1997, vol. 128, pp. 257-266
PANCHABHAI, TS, et.al, 2009. Oropharyngeal cleansing with 0.2 % chlorhexidine
for prevention of nosocomial pneumonia in critically ill patients: an open label randomized trial with 0.01 %
potassium permanganate as control. In Chest. ISSN
0012-3692, 2009, vol. 135, pp. 1150-1156.
ŠRAMOVÁ, a kol., 2010, Prevalenční studie nozokomiálních infekcí v ČR na oddělení ARO a JIP s intenzivní
umělou plícní ventilací v roce 2009. In Nozokomiální nákazy. ISSN 1336-3, 2010, roč. 9, č. 1, s. 14 – 22.
CONTACT AN AUTHOR
[email protected]
PhDr.Dana Streitová
Department of Intesive medicinae and forensic study, Faculty of Medicine, University of
Ostrava, Sylabova 19, Ostrava, 70300
[email protected]
PhDr.Renáta Zoubková
Department of Intesive medicinae and forensic study, Faculty of Medicine, University of
Ostrava, Sylabova 19, Ostrava, 70300
Tel: 731443037
233
THE INCIDENCE OF ONCOLOGICAL DISEASES IN CHILDREN'S
UNIVERSITY HOSPITAL WITH POLICLINIC BANSKÁ BYSTRICA IN
THE PERIOD 2002-2012
Šupínová Mária, Balátová Silvia
Šupínová, M: Department of Nursing, Faculty of Health Care of the Slovak Medical
University Bratislava having its seat in Banska Bystrica
Balátová, S.: Clinic of Pediatric Oncology and Haematology of the Children´s University
Hospital with Policlinic Banska Bystrica
ABSTRACT
Background: The aim of the submitted study was, based on the child-age in-patients of the
CPOH of the Children´s University Hospital with Policlinic Banska Bystrica, to map the
incidence of oncological malignancies with children between 0 and 19 years old in the period
of 2002 – 2012 and to examine the existing dependency of oncology disease incidence on the
monitored variables.
Methods: A sample of 389 child patients with a confirmed oncological malignancy was
retrospectively evaluated. Significant interactions of qualitative variables were evaluated
using Chi-quadrat test, T-test, F-test of Pearson´s coefficient (p).
Results: An analysis showed the increasing trend of the incidence of oncological diseases in
child age. The coefficient of growth was 1.035. Nor a connection of positive family
anamnesis and genesis of oncological malignancy (p=0.4565) neither a connection between
place of residence and incidence of oncological disease (p=0.5431) were confirmed in the
monitored sample. The gender-dependent incidence of diseases was not proven in the
monitored sample of respondents, however, it cannot be definitely disproved (p=0.3112). The
analysis of the results proved that the occurrence of specific types of tumours in children
defers depending on their age.
Conclusion: It is obvious from the results of the research that the number of oncological
malignancies in children is moderately increasing. The type of the oncological disease differs
depending on the age category. In the monitored sample there was not positively proven
a dependence of the genesis of oncological disease on positive family anamnesis or on place
of residence.
234
Key Words: child, cancer, incidence, age, gender.
INTRODUCTION
Cancer is a significant public health issue almost all over the world (Mikolasik, 2010 p.1).
According to the National Cancer Registry of the Slovak Republic, malignancies account for
20 – 25 % deaths being the number two right after the cardiovascular diseases
(Ondrusova,2006 p.65).
According to several specialists, the cancer incidence and mortality in all developed countries
in last decades has a trend similar to that of Slovakia. Positively viewed is the long-run steady
incidence of malignancies in children up to 15 years of age, and at the same time the moderate
decrease in mortality in this age group (Ondrusova, 2007 p.8, Buransky, 2012 p.19).
In spite the fact that malignancies in child age are rare in the Slovak Republic, their incidence
being relatively steady, the cancer incidence in the period of 1991 – 2002 varied between
115.2 and 143 / 1 million 0 – 14-year-olds and 156 –196 / 1 million of 15 – 19-year-olds.
A slight increase was only in the second group of patients (Bajciova, 2007 p.39). Also
according to Kaiserova (2007), there are in Slovakia each year approximately 150 new
diseases per 1 million of children and youth up to 20 years of age. The spectrum of
histological types of cancer in child age is age-specific and differs from the cancer spectrum
in adult age (Bajciova, 2007).
Despite the significant developments in medicine (4 out of 5 children are cured), malignancy
mortality is the number two after accidents and poisoning (Kaiserova, 2009 p.7).
Acute lymphoblast leukaemias and tumours of the central nervous system rank among the
most common malignancies in children. Until the age of 5, apart from the above mentioned,
also embryonal tumours are typical. After the age of 10, the incidence of Hodgkin´s
lymphoma, osteosarcomas and carcinomas (Kaiserova et al, 2006 p.183) rises.
In the analysis of the condition of children´s oncology in the Czech Republic in the period of
2007– 2009 (2011) Bajciova states that out of the amount of more than 70,000 malignant
tumours diagnosed each year in the Czech Republic, only 300 children until 15 years old and
approximately the same number of adolescents until 19 years old are diagnosed with an
oncological disease (Bajciova, 2011).
235
Regarding the incidence of malignancies, a moderate prevalence of boys is stated. The
proportion of boys to girls is 1.3:1. The age-specific incidence is based on the fact that the
incidence of tumours increases with age. Thus, the adolescents have, theoretically, a higher
exponential risk of tumour development than the children up 15 years old. In connection with
solid tumours in child age, experts describe two peaks of the incidence rates: the first one is at
the youngest age of 0-2, the second peak is in the period of pubescence and adolescence. The
same applies for NHL incidence rates (Bubanska). The first rise is at the age of 8, the second
one in the adolescent age. The prognosis of children with NHL depends on the histological
type and clinical stage of the disease. Presently, the survival chance is 80 – 90 % (Bubanska,
2008 p.93, Kolenova, Kaiserova, 2012 p.163).
Leukaemias make as many as 35 % of the total number of children´s oncological
malignancies. Acute lymphoblast leukaemias (ALL) represent 75 – 80 % of all leukaemias in
child age and their highest incidence rate is between the age of 2 and 5. The proportion of
acute leukaemias to chronic leukaemias is 95:5 (Kolenova, Kaiserova, 2012). In the Czech
Republic, the incidence of leukaemias is approximately 3.5/100,000 children until 15 years
old (Adam, Vorlicek, 2002 p.353).
Tumours of the central nervous system (CNS) are the most common type of solid tumours in
children and also the second most common oncological disease in child age (20 %). Their
incidence is 2.5/100,000 children, with the peak of incidence between the age of 2 and 10.
(Stancokova, 2009 p.178).
In developed countries, CNS tumours make 25 – 30 % of all tumorous diseases in children.
Their incidence is constantly rising (Schutz, Kaatsch, 2002 p.470).
The incidence of CNS tumours in children in the Czech Republic is around 9 - 110 cases per
year. Their highest incidence is in the age group under 5 years old (Pavelka, Zitterbart,
2011p.54, Novotny et al, 2000 p.5).
According to Krizova (2007), 15 to 30 years old males are most commonly struck by
Hodgkin´s lymphoma. On the contrary, the occurrence of neuroblastoma in adolescents and
young adults is very rare and it practically does not occur in adulthood (Mazanek et al, 2008
p.259, Adam et al, 2010 p.353).
According to a collective of oncology-disease specialists, external factors represent the
highest group in etiology. Based on extensive epidemiological data, their cause in the genesis
236
of all oncological diseases is estimated 75 %. Genes are ranked among the internal factors
with a 5 % participation in the genesis of all oncological diseases (Adam et al, 2003).
Martina Vorobjov mentions a relation of the occurrence of cancer and the education and place
of residence (Vorobjov, 2010 p.12).
METHODS
Delimitation of the research problem
The aim of the realized research was an analysis of the incidence of oncological diseases in
children hospitalized in the Clinic of Pediatric Oncology and Haematology (CPOH) in Banska
Bystrica from 2002 to 2012.
Research questions
1. Is there a rising trend in the incidence of oncological diseases in child age, in the context of
newly found cases hospitalized in CPOH during the previous 10 years?
2. Does a positive family anamnesis affect the incidence of oncological diseases in children?
3. Does the place of residence affect the genesis of oncological disease ?
4. Does gender of the child affect the genesis of a specific type of tumorous disease ?
5. Are there specific types of tumours depending on the age of child?
Research method
The used research method was retrospective study of medical documentation of child patients
hospitalized in CPOH from 2002 to 2012.
The aim of the study was to significant factors that would help to identify pathogenetic
mechanisms participating in the genesis of oncological diseases in children.
For the purposes of this study variable demographic factors were determined; child´s age
when disease occurred, gender, place of residence (town, village), positive or negative family
anamnesis with an accent on the occurrence of an oncological disease and the type of the
oncological disease.
Significant interactions of the above mentioned qualitative variables were evaluated using
Chi-quadrat test, t-Test, F-test, Cramer´s V coefficient and Pearson´s coefficient (p). The
results are interpreted using absolute and relative numerosity. The statistical software t Stat
was used for statistical analysis.
237
Research sample
Based on the analysis of medical documentation, the research sample consisted of 389 newly
diagnosed child oncological patients hospitalized in the Children´s University Hospital with
Policlinic Banska Bystrica in the Clinic of Pediatric Oncology and Haematology from 2002 to
2012. Only oncological child-age patients, which were diagnosed with the disease from 2002
to 2012, were included in the sample. Repeatedly hospitalized patients were not included in
the sample. Out of the total number of 389 child patients, there were 215 boys (55.27 %) and
174 girls (44.73 %).
The average age of respondents was 9.7 years.
RESULTS
2012
Tumours of head and CNS
2011
Mesenchyme tumours
2010
Kidney tumours
2009
Neuroectodermal tumours
2008
Liver tumours
2007
Eye tumours
2006
Bone tumours
2005
Genitals tumours
2004
Histiocytosis
2003
Tumour diseases of the blood:
ALL
2002
0%
20 %
40 %
60 %
80 %
100 %
Figure 1. Distribution of respondents by types of tumour disease
In the sample of 389 child-age oncological patients we found out that the spectrum of tumours
was varied. It is obvious from the processed data that the highest representation have the
tumours of head and CNS and haematologic oncological diseases.
238
Table 1 Rate of growth of oncological diseases in 2002 - 2012
year
n
rate of growth kt
2002
33
2003
32
0.96
9
2004
41
1.28
1
2005
25
0.60
9
2006
45
1.80
0
coefficient of growth
2007
34
0.75
5
1.035
2008
45
1.32
3
2009
24
0.53
3
2010
38
1.58
3
2011
25
0.65
7
2012
47
1.88
0
Table 1 shows an overview of the umber of newly diagnosed patients in each year of the
monitored period. The coefficient of growth expresses that the number of children with an
oncological disease increase each year, on average, by 3.6 %.
Table 2 The incidence of oncological diseases in the monitored years by gender
Gender
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Total
%
Male
20
21
25
9
28
21
24
15
20
11
21
215
55.27
Female
13
11
16
16
17
13
21
9
18
14
26
174
44.73
Total
33
32
41
25
45
34
45
24
38
25
47
389
100.00
p
0.311
t Stat
1.654
F
1.474
p= Chí – quadrat test; significance level  = 0.05, df = 10; T-test; t(Critical two-tail) = 2.0860; F-test- Fkrit = 2.9782
There was a slight prevalence of boys in the total incidence of oncological diseases (Table 2).
Dependence was statistically verified between the incidence of oncological disease and the
age of patients. The statistical verification did not prove the dependence (Table 2).
The total incidence of malignancies in the individual age categories is presented in table 3.
Table 3 Distribution of respondents by age and diagnosis
Tumors
Tumours of head and CNS
Mesenchyme tumours
Kidney tumours
Neuroectodermal tumours
Liver tumours
Bone tumours
Genitals tumours
Eye tumours
Histiocytosis
Haematological
Total
(0; 1>
%
6
2
4
3
2
0
0
3
1
3
(1; 3 >
%
10
0
3
8
1
0
0
0
2
20
(3; 6 >
%
19
2
10
3
0
1
1
0
0
30
(6; 10 >
%
12
6
2
1
0
3
0
0
2
27
(10; 15 >
%
39
9
4
1
3
9
8
0
0
38
(15; 19 >
%
13
8
1
0
0
7
5
1
0
56
24
44
66
53
111
91
6.17
11.31
16.97
13.62
28.53
23.39
Total
389
The above mentioned implies that the incidence of the individual types of tumours is in
various age categories different (Table 3).
239
Table 4 Growth of the incidence of all types of diseases in relation to age
Disease at the age of
all types - total (n)
rate of growth (kt )
(0;1 >
24
coefficient of growth ( )
1.31
(1;3 >
44
1.833
(3;6 >
66
1.500
(6;10 >
53
0.803
(10;15 >
111
2.094
(15;19 >
91
0.820
Relation was statistically verified between the age of respondents and the incidence of
oncological diseases. The coefficient of growth of 1.31 means an average growth in the
incidence of diseases by 31 % in relation to individual age categories (Table 4). The same
value of growth was calculated using RATE function (31 %).
Table 5 The incidence of malignancies in respondents in relation to residence
Residence 2002 2003 2004 2005 2006 2007 2008
Town
14
13
18
15
24
15
28
Village
19
19
23
10
21
19
17
Total
33
32
41
25
45
34
45
p
0.543
p= Chí – quadrat test; significance level  = 0.05, df = 10
2009
12
12
24
2010
15
23
38
2011
11
14
25
2012
25
22
47
Total
190
199
389
%
48.84
51.16
100.00
Based on the result of the statistical verification the incidence of oncological diseases in our
sample is not related to the place of residence p=0.543, it does not depend on whether
children live in a town or in a village.
Table 6 The incidence of malignancies in relation to family anamnesis
Year
FA+
2002
17
2003
9
2004
7
2005
7
2006
9
2007
3
2008
7
2009
4
2010
10
2011
7
2012
12
Total
92
%
23.65
average
8.36
dispersion
14.65
p
0.010
V
0.243
p= Chí – quadrat test; significance level  = 0.05, df = 10; V=Cramer´s coefficient
FA16
23
34
18
36
31
38
20
28
18
35
297
76.35
27.00
68.00
Dependence between positive family anamnesis and the incidence of oncological disease in
our sample was statistically verified and we found out that there is a relation between the
monitored variables. The intensity of the relation was measured using Cramer´s V coefficient.
Its value of V = 0.243 represents a low-to-moderate dependence (Table 5).
240
DISCUSSION
The incidence of child-age oncological malignancies has an increasing trend in the monitored
sample, on average by 3.6 % (Table 1). It is proven by the coefficient of growth (1.035).
Kaiserova (2009) observes that the incidence of child-age malignancies in Slovakia is
relatively steady. Yearly, there are approximately 150 new diseases per 1 million children and
youth until the age of 20. Also in the Czech Republic, as Bajciova (2011) states, there are
around 300 newly diagnosed children per year.
Statistically we verified the dependence between the respondents gender and the frequency of
an oncological disease. Despite the slight numerical superiority of boys (55.27 %) in the
monitored sample, statistical testing did not prove a dependence of children´s gender and the
occurrence of oncological disease (Table 2). In the incidence of malignancies, Bajciova
(2011) states a slight superiority of boys to girls (ratio 1.3:1) that does not change in the
course of age.
Several authors (Bajciova, 2011, Krizova, 2007, Adam, Vorlicek, 2002, Kolenova, Kaiserova,
2012 and others) connect the incidence of specific types of tumours with a certain age group
of patients. Also the very incidence of oncological diseases is related to the age of patients.
The results of our study are in compliance with the above mentioned statement. The age
groups having the highest incidence of tumour diseases are 10;15 > and 15;19 > (Table 3).
The average growth of the incidence of diseases in relation to age categories is 31 % (Table
4).
Epidemiologic studies, as stated by Pope et al (1995), realized in the course of several
decades, revealed that a long-stay in towns with an increased air pollution by products of
combustion is related to an increased cardiovascular and oncological morbidity and mortality
rate. Also Vorobjov (2010) suggests a relation of the occurrence of cancer and the education
and place of residence. The dependence of the occurrence of cancer on the place of residence
was not proved in the monitored sample (Table 5).
According to experts, the occurrence of cancer is connected with family anamnesis.
Kristinsson et al, (2012) state that the first-degree relatives have an increased hazard of the
genesis of some lymphoproliferative disorders, but not other malignancies.
Nelson (2005) stated that breast and ovarian cancer was connected with family anamnesis. He
proved the action of BRCA1 and BRCA2 genes that were identified as clinically significant in
241
breast and ovarian cancer susceptibility. It is estimated that the incidence is approximately
from 1: 300 to 500 in the whole population. In our monitored sample, 23.65 % of respondents
had positive family anamnesis. The statistical proving showed a weak to moderate
dependence (table 6) which would require further verification on a larger sample of
respondents.
CONCLUSION
Tumour diseases in child age are rare. The cause of most types of tumours is unknown.
The aim of the submitted article was, based on the child-age in-patients of the CPOH of the
Children´s University Hospital with Policlinic Banska Bystrica, to map the incidence of
oncological malignancies with children between 0 and 19 years old in the period of 2002 –
2012 and to examine the existing dependency of oncology disease incidence on the monitored
variables. Our intent was to find significant factors that would help to identify pathogenetic
mechanisms participating in the origin of oncological diseases with children. The study
results imply a moderate increase in oncological diseases with children. The type of
oncological disease differs depending on age category. The dependence of the occurrence of
an oncological disease on the positive family anamnesis and on the place of residence was not
positively proved in the monitored sample.
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CONTACT AN AUTHOR
PhDr. Mária Šupínová, PhD.
Department of Nursing,
Faculty of Health Care of the Slovak Medical University Bratislava
having its seat in Banska Bystrica
Sladkovicova 21
97405 Banska Bystrica
Slovac Republic, Europe
e-mail: [email protected]
243
COMPETENCE OF ACADEMIC STAFF – PhD SUPERVISORS IN THE
NURSING STUDY PROGRAM
Tučková Dagmar, Olecká Ivana, Juríčková Lubica, Ivanová Kateřina
Department of Social Medicine and Public Health, Faculty of Medicine and Dentistry,
Palacký University Olomouc
ABSTRACT
Background: Nursing PhD program was established at the Faculty of Health Sciences in
2008 (accreditation lasts until 2016). Its duration is set to 3 years. The successful finish of the
PhD study is a complex (not only) time-consuming activity. One of the most important
aspects for functional operation of the doctoral program is competent supervisors. The aim of
the paper is to present the research design and partial results obtained during the research
competencies of academic staff – supervisors who have an experience with a supervision of
PhD students at the Faculty of Health Sciences at Palacký University in Olomouc.
Methods and sample: The research design was designed to bring basic knowledge
concerning the competence of supervisors not only in the doctoral program of Nursing at the
Faculty of Health Sciences, Palacký University in Olomouc. The basic research question was:
What are the competencies of the supervisor which lead to successful completion of PhD
study?
The research was conducted in four stages; It was attended by two target groups: (1)
academics who hold the rank of supervisor in non-medical fields and have experience with
leading Ph.D. students - paramedical staff; (2) students / graduates in the doctoral programme
of Nursing.
In the first phase was conducted a literature review and determination of the term of
competence. The second phase included the collection of data through semi-structured
interviews with academic staff with the rank of supervisor and the second target group
conducted focus group. The third phase included an analysis of the data obtained from the two
groups. It was a frequency analysis of semi-structured interviews with the first group; sorting
and rating findings from focus group with the second group. Plan of the fourth stage involves
the formation of a quantitative tool (questionnaire) for the diagnosis of competencies of
supervisors in the doctoral study programme of Nursing at the Faculty of Health Sciences at
Palacký University in Olomouc.
244
Results: In the first phase, searches of literary sources were conducted and on the basis of this
research the term of competence was determined. The second phase brought knowledge from
both analyzed target groups that will be compared and interpreted for the purposes of the
fourth phase of research (quantitative instrument).
Conclusion: Research design is designed to bring basic knowledge concerning the desirable
competencies of academic staff - supervisors in the doctoral program of Nursing.
Key Words: competence, academic staff, supervisor, doctoral study program, students of the
Faculty of Health Sciences Palacký University in Olomouc
INTRODUCTION
According to Directive of the dean of Faculty of Health Sciences to Study and Examination
Regulation, Palacký University in Olomouc, the PhD supervisor annually evaluates the
progress of doctoral studies according to student´s individual study plan and gives reason for
recommendation (or non recommendation) to continue studying. At the end of doctoral study
he/she provides statement about a dissertation. Every supervisor should have acquired
competencies by which he/she leads the PhD student to successful completion of doctoral
study program (hereinafter DSP). Competence are structured according to the model by the
National System of Occupation in the Czech Republic (hereinafter NSO). Structure of NSO
competence model includes: soft skills, general skills, professional knowledge and skills1.
The definition of the term (key) competence is not uniform. M. Tureckiová and J. Veteška
(2008, p 27) define the term competence as a unique person´s ability to act successfully and to
develop own potential on the basis of integrated set of individually specific sources (abilities,
skills, knowledge, experience, attitudes, values et) in specific context of different tasks,
activities and life situations connected with a ability and willingness (motivation) to make
decisions and to take responsibility for own decisions.
As reported by C. Klimeš and P. Kazík (in Vaněk et al, 2013, p 25), a university teacher
competency model expresses a set of knowledge and skills which should be used by the
teacher for his/her profession performance; and it is comprised of:
 professional knowledge and skills,
1
NSO competence mod. Competence Database. [online] Prague: National System of Occupation. Available
from: http://kompetence.nsp.cz/napoveda.aspx
245
 general skills,
 soft competence (cf. with the NSO competence model).
But the question still remains what competencies should the supervisor have to lead the PhD
student successfully to completion of his/her DSP? P. Gill and P. Burnard (2008, p 668) state
that the crucial importance in PhD leadership should be placed mainly on the teaching,
leading, referral and support. Trinity College Dublin (University of Dublin, 2011, p 4)
published a table mapping key competencies which make the practice of PhD supervisors
more effective. Among key tools belong: prerequisites for PhD study which the PhD
supervisor checks, PhD student – supervisor relationship, supervisor´s assistance, supervision
of doctoral research, PhD student´s training and development, student welfare duties,
supervisory competence, supervisory supervision.
Dr. L. Barnett (2012, p 3) states, that PhD study is created by nine basic components. The first
phase is a recruitment and selection of PhD student during which students are introduced to
the formal requirements and are integrated to an academic life. The second step is to build the
PhD student – supervisor relationship, which according to Barnett lasts about one year. The
third component involved in the leadership is annual assessment of the PhD student, his/her
progress and persisting mapping his/her development. Barnett includes among other
activities/components supervisor´s own research, support and help in writing research papers,
publications of PhD student etc., help in writing and defence of the dissertation, preparation
for the future carrier etc.
However, some problems, which arise from the different expectations of supervisors or PhD
students, can occur during leaderships.
P. Gill and P. Burnard (2008, p 669-670) in their work indicate expectations which PhD
students have from their supervisors. These are as follows:

support, encouraging, leadership and providing advice,

criticism, if is appropriate, in a constructive and encouraging way,

to be available,

to read and comment written papers within a reasonable time,

if it is available to ensure that student has appropriate equipment and resources for work,

to ensure that student has available research tools and other necessities and required
training,
246

to assist in writing of the reports on the student progress,

to be enthusiastic, committed, knowledgeable and accessible,

if it is possible and appropriate to help students with academic and personal problems
which could disturb the smooth running of the research.
Our research was focused on analysis of the supervisor competence in leadership of PhD
students in DSP in non-medical fields. The aim of the paper is to present the research design
and partial results gained in competence research of academic staff – the supervisors who
have experience with PhD student leadership in DSP at Faculty of Health Sciences, Palacký
University Olomouc.
METHODS AND SAMPLE
Research design was conceived to make a basic overview of the academic staff competencies
in PhD student leadership in DSP. From the above it is clear that competencies refer to a set
of knowledge, skills, abilities, attitudes and values which mingle together and are important
for development of every member of society. The basic question of the research methodology
was: What are the competencies of the supervisor which lead to successful completion of PhD
study? The research was divided into four phases.
In the first phase literature research was carried out. Research strategy with using PICo 2
(evidence-based approach) for qualitative research was used for this aim. The PICo was
determined as follows:
P – academic staff; I – competence; academic staff having competencies, influencing of the
PhD student competence level, size/range of experience in the supervisor’s competence in
PhD leadership; C – successful completion of PhD study.
Literature research was performed in ERIC, ProQuest Educational Journal, Google Scholar
databases. The term competence was determined on the basis of found out information from
the literature research
The second phase involved an implementation of planned qualitative research. The first
researched group was created by academic staff with the rank of supervisor in non-medical
field that has experience with PhD leadership in non-medical field. A semi-structured
2
If it is PICo search strategy for qualitative reseach it is necceesary to define P (People, problem), I (Phenomena
of Interest), C (Context); O (Outcomes) is it not neccesary to define. That is the reason we did not define
„outcomes“ in our research.
247
interview was chosen as a data collection technique. It was built on the basis of findings
gained from the literature research.
The semi-structured interview consisted of three contact questions. Next seven questions were
focused of the leadership in DSP itself. 19 academic staff with the rank of supervisor in the
paramedical fields, who have experience with PhD leadership in non-medical field, was
approached. Research was carried out in March 2014. Expected completion of data collection
from semi-structured interview is planned for August 2014. Participation in the research was
voluntary.
The second research group were students/graduate in DSP Nursing. The thematic analysis
gained from the focus group was chosen as a data collection technique. Research with the
second group was divided into seven partial successive steps: (1) contact, (2) protocol, (3)
brainstorming, (4) expression synthesis, (5) sorting, (6) rating, (7) creating maps +
interpretation. All PhD students were approached. Research was carried out in June and July
2014. Participation in the research was voluntary.
RESULTS
Nine academic staff was interviewed within the first research group which consisted of
academic staff having experience with PhD leadership in non-medical field (to July 2014).
The analysis of each interview was done. The most often represented activities, abilities,
skills, attitudes and values, which were determined as necessary for supervisor to successful
completion of PhD study by the PhD student, are listed in Table 1.
Table 1 Activities, abilities, skills, attitudes and values of academic staff – supervisors from
the perspective of supervisors
Activities, abilities, skills, attitudes and values
Knowledge of methodology
Willingness to cooperate
Ability to motivate
Lead PhD student to self-reliance
Ability to lead
Knowledge of own field specialization
Ability to communicate
„Face to face“ communication
To be responsible
Be able to write a scientific article, and publish
To have international competence
To be flexible
To create personal relationship with PhD student
To be democratic
Ability to speak English
Ability to search in databases
Ability to create *ppt presentations
To carry out their own research
Number of supervisors who listed it:
9
7
6
6
5
4
4
4
4
4
3
2
2
2
2
2
2
2
248
As shown in Table 1, 100 % of supervisors stated the knowledge of methodology as a key for
successful leadership of the PhD student. 77, 7 % of supervisors stated that willingness to cooperation with the PhD student is necessary. 66, 6 % of supervisors stated that the supervisor
should be able to motivate and encourage students to become independent. 44,4 % of
supervisors stated that it is important to orientate in their own field, to communicate with PhD
student and to be able to communicate „face to face“, to be responsible and to publish. 33, 3
% of supervisors stated that the supervisor should have international competence. 22, 2 % of
supervisors stated that it is important to create good relationship with the PhD student, to be
flexible, democratic, to be able to speak English, to be able to search in databases, to be able
to create PowerPoint presentations and to carry out their own research.
Because this second phase has not been finished we are presented only partial results gained
from the competence research of academic staff – supervisors at the Faculty of Health
Sciences, Palacký University in Olomouc.
The method of focus group was chosen for the research with the second group which was
created by students/graduates in DSP Nursing. Brainstorming method was done with 4
volunteers from the students DSP at Faculty of Health Sciences in June. Expression synthesis
was gained from the gained findings – 54 statements were determined (see Table 2)
Table 2 Expression/statements synthesis for sorting and rating
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Supervisor does not cause chest tightness.
Supervisor teaches critical thinking
Supervisor has the ability to lead / lead can.
Supervisor is orientated in the issue.
Supervisor motivates to study.
Supervisor is patient.
Supervisor himself/herself goes as an example.
Supervisor teaches scientific thinking.
Supervisor gives objective feedback.
Supervisor motivates PhD student to self-study
Supervisor determines the boundaries.
Supervisor forces PhD student to work on himself/herself.
Supervisor has to have personality in terms of education, but also character traits.
Supervisor has to have background.
Supervisor is professional within co-operation.
Humanity - comprehension that we are still learning.
Supervisor has to be a good teacher.
Supervisor has his/her own interest in the leadership.
Supervisor supports mutual co-operation in publishing.
Supervisor provides additional contact, information.
Supervisor is critical to himself/herself.
Supervisor admits his/her own fallibility.
Supervisor is a partner with the PhD student.
Supervisor can put information into context.
Supervisor is able to think in a structured way.
249
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
Supervisor can read between the lines.
Supervisor is able to help at every stage of PhD study.
Supervisor is authority in the relationship.
Supervisor must be at least one step ahead.
Supervisor should let the PhD student to express his/her own ideas, but to correct them that the work
does not go somewhere else.
Supervisor affects the PhD student and personal life.
Supervisor teaches PhD student how to lead his/her own students.
Supervisor should be able to offer assistance by himself/herself when the PhD student feels that he/she
is at the end of forces.
Supervisor should always be prepared for everything.
Supervisor regularly communicates and consults.
Supervisor determines the terms.
Supervisor himself/herself follows deadlines.
Supervisor supervises PhD student to comply with the agreed terms.
Supervisor must be able to move PhD student on.
Supervisor must be able to recognize your own mistakes.
Supervisor cannot be self-centred.
Teamwork.
Supervisor should have emotional intelligence.
Supervisor should be able to see and appreciate the efforts of PhD student.
Supervisor is precise, consistent.
Supervisor gives space to mature and do not hurry to PhD student.
Supervisor is emotionally balanced.
Supervisor is factual.
Supervisor is empathetic.
Supervisor support students when he/she breaks down.
Supervisor uses the words "we are together". Does not throw everything only to the doctoral student.
Supervisor should have just as many PhD students as he/she is able to lead.
Supervisor should be willing to fight for the PhD student at the dissertation defence.
PhD student is supervisor´s image so the supervisor would treat accordingly.
In the next phase of the research, the same group of volunteers from the students DSP at
Faculty of Health Sciences got the task to do sorting and rating on the basis of the categories,
which they created themselves. They divided individual statements into these categories. The
categories represent key competencies the supervisor should have from the perspective of
PhD students, and statements they assign to them (see Table 3).
Table 3 Categories determined supervisor´s competencies – from the perspective of PhD
students
PhD student no.
1
Categories
Supervisor as a manager
Number of statement
9, 19, 20, 24, 29, 36, 48
Professionalism of the supervisor
Supervisor as a partner
2, 3, 4, 8, 11, 12, 14, 17, 25, 27
15, 23, 28, 30, 31, 32, 33, 35, 38, 39, 42, 44, 46,
50, 51, 52, 53, 54
1, 5, 6, 7, 10, 13, 16, 18, 21, 22, 26, 34, 37, 40, 41,
43, 45, 47, 49
2, 3, 4, 5, 6, 7, 8, 13, 14, 17, 20, 21, 24, 25, 26, 28,
29, 34, 35, 44
9, 11,30, 36, 37, 38, 45, 53
1, 10, 15, 16, 18, 19, 22, 23, 27, 31, 33, 39, 40, 41,
42, 43, 47, 48, 49, 50, 51, 52
12, 32, 46, 54
Supervisor´s personality
PhD student no.
2
Scientific quality
The correctness of leadership
Emotions
Ability to motivate
250
PhD student no.
3
Supervisor´s personality
1, 6, 7, 13, 16, 21, 22, 23, 28, 33, 40, 41, 43, 47,
49, 50
3, 9, 11, 35, 36, 37, 38, 42, 44, 45, 48, 51, 52, 53,
54
2, 4, 5, 8, 10, 12, 14, 15, 17, 18, 19, 20, 24, 25, 26,
27, 29, 30, 31, 32, 34, 39, 46
Managerial skills and abilities
Scientific skills
In the next phase, PhD students did rating of individual statement according to importance
and urgency which should indicate on Likert scale. A special form was created for this
purpose. All statements were listed in this form together with spaces for indication of the
importance and urgency.
The importance was indicated within listed statements according to how much they can help
to academic staff/PhD student in DSP (Likert scale – (1) very helping, (2) helping, (3) little
helping, (4) unhelpful).
The urgency answers the question: If there is the possibility to help in doctoral study program,
how will you proceed? What are the things you would solve immediately (immediately) or
which could wait and which would be almost useless? (Likert scale: 1. Urgent, we would
solve it immediately; 2. Very important, but we would solve it later; 3. Interesting, but it may
not be solved at all; 4. Almost unnecessary).
The same form as used for PhD students-volunteers was sent to all other PhD students at
Faculty of Health Sciences, Palacký University in Olomouc. All gained data will be processed
and so called go-zone maps will be created. Results of sorting and go-zone maps will be
interpreted and they will help as a base for quantitative measuring tool creation for need of
competence diagnostic at Faculty of Health Sciences, Palacký University in Olomouc, DSP
Nursing.
DISCUSSION
Research was originally focused mainly on academic staff that has experience with PhD
leadership. It can be said that the basic elements in the determination of the term competence
are knowledge, skills and experience; sometimes attitudes, values, personal characteristics or
individual dispositions are added. Competence can be defines as a combination of skills,
knowledge, abilities and attitudes which are needed by individual to supervisor´s own
development and to use in working life; therefore we can define them as the key
competencies. Acquisition and development (key) competencies are for the PhD supervisor
the main tool for better efficiency during PhD student leadership.
251
It is not possible to make conclusion on the basis of finding we gained because the research is
still ongoing. However, 100 % of the previously analyzed interviews with academic staff
experienced with PhD leadership stated that the most important competence in PhD
leadership is methodology knowledge. If we consider the structure of NSO competencies
model, this competence belongs to the category "Professional knowledge and skills." P. Gill
and P. Burnard (2008, p 669) state that the most important is the supervisor-PhD student
relationship which cannot be clearly defined as the competence of one or the other side but it
involves different competencies both involved sides. It is possible to say it is a relationship in
which interaction should work. Sheehan (1993, p 882) states that relationship between the
supervisor and the PhD student should be emotionally and intellectually on the level and
that´s the reason why it is created for several years (cf. Barnett, 2013, p 22-23). Good
leadership from the supervisor includes providing of a sufficient amount of encouragement,
support, constructive and critical approach, encouraging and developing independent thinking
and other ways of work.
CONCLUSION
The research showed both PhD students and supervisors put emphasis on good relationship
with each other. But there exist many factors which can influence the PhD student-supervisor
creation of relationship itself. And that is why the question remains premise: „If the
supervisor is competent, is the PhD student competent as well?“ and vice versa.
Dedicated: Support of Human Resources in Science and Research
Research in Non-medical Healthcare
at the Faculty of Health Sciences at Palacký University Olomouc
CZ.1.07/2.3.00/20.0163
REFERENCES
VANĚK, J. a kol.. Rozvoj klíčových kompetencí pracovníků vysokých škol. Opava: Studia Oeconomica. 2013.
ISBN 978-80-7248-922-0.
TURECKIOVÁ, M., J. VETEŠKA. Kompetence ve vzdělávání. 1. vyd. Praha: Grada, 2008. 160 p. ISBN 97880-247-1770-8.
P. GILL, P- BURNARD. The student-supervisor relationship in the phD/Doctoral process. British Journal of
Nursing. 2008, Vol 17, No 10. p 668-671. ISSN 0966-0461.
BARNETT, L. Handbook. For PhD Supervisors. LSE:Teaching and Learning Centre. 2012.
SHEEHAN, J. Issues in the supervision of postgraduate research students in nursing. J adv nurs. 1993, Vol 18,
No 6. p 880-5. ISSN 0309-2402.
NSO competence mod. Competence Database. [online] Prague: National System of Occupation. 2012, [cit.
2014-19-9] Available from: http://kompetence.nsp.cz/napoveda.aspx
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Trinity College Dublin. Table Mapping Key Concepts of Effective Supervision from the Literature to the TCD
Guidelines. [online] University of Dublin. 2011, [cit. 2014-19-9] Available from:
https://www.tcd.ie/history/undergraduate/handbooks.php
CONTACT AN AUTHOR
Mgr. Dagmar Tučková, Ph.D.
Depatrment of Social Medicine and Public Health, Faculty of Medicine and Dentistry,
Palacký University
Hněvotínská 3, Olomouc 775 15, Czech Republic, Europe
e-mail: [email protected]
253
THE EFFECT OF METABOLIC SYNDROME ON PSYCHE
Vévodová Šárka, Kučerová Kateřina, Vévoda Jiří, Merz Lukáš
Vévodová, Š., Merz, L.: Department of Humanities and Social Sciences, Faculty of Health
Sciences, Palacký University in Olomouc
Kučerová, K.: University Hospital in Ostrava
Vévoda, J.: Department of Social Medicine and Public Health, Faculty of Medicine and
Dentistry, Palacký University Olomouc
ABSTRACT
Background: Some of the civilisation diseases, including the metabolic syndrome, arise due
to infringement of rules for psychic hygiene and wrong eating habits. Mood disturbances and
depression are concurrent with the metabolic syndrome as well. The aim of the research was
to find out the rate of depression and anxiety in people with metabolic syndrome, their quality
of life and the effect of anxiety and depression on quality of life.
Methods: The research sample comprised 114 patients treated for the metabolic syndrome.
A control group consisted of 116 respondents. Three standardised questionnaires were used:
Beck Anxiety Inventory, BDI-II and WHOQOL-BREF. The data were collected in 2013.
Statistical processing included the Mann-Whitney test, t-test and Pearson correlation
coefficient.
Results: The survey research results show that there is a significant difference in the rate of
anxiety (p=0.000) and depression (p=0.000) between the studied sample and the control
group. Patients with metabolic syndrome also have a significantly lower quality of life
(p=0.000). Depression (r= -0.624) as well as anxiety (r= -0.328) in patients with metabolic
syndrome lead to generally lower quality of life in comparison to the control group.
Conclusion: Psychic disorders, which might be the cause or consequences of the metabolic
syndrome, lie on the periphery of somatic care. Patients with this particular disease should be
provided with psychological intervention as well.
Key words: metabolic syndrome, anxiety, depression, quality of life, nursing care, BDI-II,
Beck Anxiety inventory, WHOQOL-BREF.
254
INTRODUCTION
On the one hand, thanks to modern technology and progress in medicine, human life
expectancy is being constantly extended. On the other hand, lives are shortened and the
quality of lives is lower due to bad mental hygiene and chiefly because of unsuitable eating
habits. As a result, lifestyle diseases are on the rise – including the metabolic syndrome
(Pavlatová, 2010). Among the symptoms of the metabolic syndrome are high blood pressure,
dyslipidemia (high levels of triglycerides and lower HDL) and presence of small LDL
particles, hyperuricemia, abdominal obesity, microalbuminuria, disturbance in glucose
tolerance, hypomagnesemia and higher level of plasminogen activator inhibitor 1 (Karen,
Souček et al., 2007, p. 122; Krahulec, 2005, p. 161). Adams, Appleton et al. claim that waist
circumference higher than 94 cm in men and 80 in women are the symptoms of metabolic
syndrome (Adams, Appleton et al., 2005, p. 2777).
Amongst individuals with metabolic syndrome, the central nervous system is negatively
affected by the metabolic factors. The increased level of blood lipids may interfere with
transportation of hormones affecting the psyche and consequently hormone deficiency occurs,
which might be one of the causes of depression (Hess, 2012). Some studies suggest that
obesity as a component of the metabolic syndrome (MS) contributes to increased anxiety
(Janyšková, 2007, p. 3). Research conducted by Lamberta et al. shows that in individuals with
the MS, the hypothalamic-pituitary-adrenal axis is activated, including the sympathetic axis of
the CNS, which leads to the development of anxiety and depression (Lambert et al., 2010, p.
543 - 550). Caroll et al. pointed out, that some affective disorders, including anxiety, may in
later years contribute to the development of some of the symtoms of the metabolic syndrome.
The MS may be the cause as well as the consequence of anxiety disorders, because of the MS
components, such as high blood pressure, causes anxiety in patients (Caroll et al., 2009, p. 91
- 93).
The link between MS and depression has recently been disputed, despite several studies
conducted on this issue (Richter, Juckel, Assion, 2010, p. 41). The above mentioned relation
was described by Zeman, Jirák, Žák et al. (2008, p. 75), who claim that the presence of the
MS multiplies the risk for the development of depression. Hess noted in an interview that the
MS may be either the cause or the consequence of depression (Hess, 2013).
Some authors regard the MS as the result of psychic disorders (Gaysina et al., 2011, p. 752;
Caroll et al., 2009, p. 91-93; Rosolová, Podlipný, 2009, p. 650). Antidepressants, anxiolytics,
255
and other psychiatric drugs undoubtedly bring a significant relief for patients suffering from
psychic disorders. However, side effects, among which are also metabolic disorders, are
associated especially with long-term use (Češková, 2006). Another opinion considers MS as
one of the causes of psychic disorders (Svačina, 2004; Lambert et al., 2010, p. 543-550;
Zeman, Jirák, Žák a kol., 2008, p. 75; Podlipný, Hess, 2006, p. 69; Rosolová, Podlipný, 2009,
p. 650).
Some symptoms of the MS, e.g. obesity, insulin resistance and high blood pressure, are linked
with decreased quality of life. The metabolic syndrome itself decreases quality of life (Vetter
et al., 2011, p. 1087 - 1094). Roohafza et al. state in a cohort study that people with the MS
have not only a decreased quality of life including physical and social function, but also a
changed psychic condition. For this reason, the treatment of MS should be conceived as a
complex treatment, i.e. including psychological support (Roohafza et al., 2012, s. 2 - 6). The
results by Miettola et al. show that people with the MS have a significantly lower compared to
respondents without MS, namely in areas of mobility, breathing, hearing, usual ADL’s,
discomfort and health issues, vitality and sex life (Miettola et al., 2008, p. 1055-1062).
From the perspective of patient care, it is good to know that the consequences of obesity and
the related MS are not only physical, but also psychic. These factors tend to be
underestimated and lead to further worsening of the symptoms of MS (Skálová, 2013, p. 26 27).
The aim of the research was to ascertain, whether psychic anxiety disorders and depression
occur in patients with MS and to ascertain the quality of life amongst these patients. Five
hypotheses were set: 1) There is a significant difference in the rate of anxiety measured with
the Beck Anxiety Inventory (BAI) between the research group and the control group. 2) There
is a significant relation between the rate of anxiety measured with BAI and quality of life
measured with WHOQOL-BREF questionnaire. 3) There is a significant relation between the
rate of depression measured with Beck Depression Inventory (BDI) between the research
sample and the control group. 4) There is a significant relation between the rate of depression
measured with BDI and the quality of life measure with the WHOQOL-BREF questionnaire.
5) There is a significant difference in the quality of life measured with the WHOQOL-BREF
questionnaire between the research sample and the control group.
METHODS
256
The quantitative approach was selected for the research. To acquire data, standardised
questionnaires were used: Beck Anxiety Inventory, Quality of Life – WHOQOL-BREF
(questionnaire by WHO, shorter version) and BDI-II (Beck Depression Inventory).
The research was conducted in the University Hospital in Olomouc on the following
departments: I. internal Cardiologic Clinic, II. Internal Gastroenterology and Hepatology
Clinic, Clinic of PE Medicine and Cardiovascular Rehabilitation and the Department of
Therapeutic Nutrition. These workplaces were selected due to the highest number of patients
treated for MS. Patients included in the research were treated for MS and were in regular outpatient care, selected using simple purposive sampling. The control group comprised of
respondents who were not treated for MS or any other chronic disease. An informed consent
was obtained from the patients. The research survey was carried out from the middle of May
until the end of September 2013.
The SPSS 19 Base was used for statistical processing. To ascertain the data distribution
normality, the Kolmogorov–Smirnov test was used. To calculate the significance level
between the groups, the Mann-Whitney and Student t-test were used. The tests were
performed on a significance level α = 0.05. To verify the significance of a relation, the
Pearson product-moment correlation coefficient was employed. The significance level was set
at α = 0.01.
RESULTS
The research survey included 114 patients, 58 (50.7 %) women and 57 (49.3 %) men. The
group average age was 43.5 years. The control group consisted of 116 respondents, 60 women
and 56 men. The group average age was 37 years.
Based on the BAI, an anxiety state of medium-severity was discovered in 78 and severe
anxiety in 62 out of 114 patients.
To find out whether there is a significant difference in the rate of anxiety between the research
and control group, the non-parametric Mann-Whitney test was used. The acquired results
show that the anxiety rate is significantly different in individuals with MS compared to
healthy individuals (p=0.000). The alternative hypothesis was approved.
Another aim was to ascertain the depression rate in individuals with MS. Using the BDI-II, a
light depression was found out in 24 respondents out of 114, depression of medium severity in
18 and a severe depression in 4 respondents. To verify the difference significance between the
257
research and control group, the Mann-Whitney test was used. It was confirmed that the
research group has a significantly higher depression rate compared to the control group
(p=0.000).
The third aim was to ascertain the quality of life amongst people with MS.
Table 1 Average values in each domain of the WHOQOL-BREF in research group.
Sex3
Women
Men
n ( %)
Q1
Q2
58
57
3.4
3.5
2.7
3.0
DOM 1
(PH)
12.9
13.9
DOM 2
(P)
13.9
14.8
DOM 3
- (SR)
14.1
14.7
DOM 4
(E)
13.3
13.8
OS
60.2
64.2
Table 1 clearly shows that the average values in each domain of quality of life are higher in
men with the MS compared to women, which might indicate better quality of life amongst
men the MS. However, this difference is not significant. The quality of life in both men and
women with MS is the same.
Table. 2 Average values in each domain of the WHOQOL-BREF in the research and control
group.
Group
Research sample
Control group
N
114
116
Q1
3.5
4.6
Q2
2.8
4.1
DOM 1 (PH)
13.4
17.3
DOM 2 (P)
14.2
17.0
DOM 3 (SR)
14.1
16.8
DOM 4 (E)
13.5
15.7
OS
62.2
74.9
To ascertain whether there is a significant difference in quality of life between the research
and control group, the Student t-test was used. Based on the acquired results, we can say that
the research group has a significantly lower score in quality of life compared to the control
group (t = 1.219; p=0.000).
Table 3 compares the result between the research and the control group with the population
norm.
Table 3 Comparison of average results of the WHOQOL-BREF between the research group,
the control group and the population norm
Group
Research sample
Control group
Population norm
Q1 - r
3.58
4.3
3.82
Q2 – r
2.96
4.25
3.68
DOM 1 (PH) - r
13.52
17.31
15.55
DOM 2 (P) - r
14.37
17.00
14.78
DOM 3 (SR) - r
14.36
16.84
14.98
DOM 4 (E) - r
13.69
15.87
13.30
Table 3 shows that the average score of quality of life amongst the research group and lower
than the population norm in all the domains.
3
n = number of respondents; Q1 = overall quality of life; Q2 = health; DOM 1 (PH) = Domain 1 (Physical
health); DOM 2 (P) = Domain 2 (Psychological); DOM 3 (SR) = Domain 3 (Social Relationships); DOM 4 (E) =
Domain 4 (Environment); OS = overall quality of life score
Note: scale in the domains ranges between 4 - 20, in items Q1 and Q2 between 1-5
258
Another aim of the research was to ascertain how the presence of depression and anxiety
amongst people with the MS affects quality of life. In order to learn about the relation
between anxiety and quality of life, the Pearson correlation was used. It was established that
there is a significant negative relation between the rate of anxiety and the rate of overall
quality of life (r = - 0.328 p0.01). Thus, anxiety leads to lower quality of life amongst patients
with MS.
To find out the relation between depression and quality of life, the Pearson correlation was
used again. There is a significant negative relation (r = - 0.624 p0.01) between depression rate
and overall quality of life. Depression, as well anxiety, leads to lower quality of life amongst
patients with MS.
As it is clear from the findings, the metabolic syndrome leads to lower quality of life among
MS patients. Depression and anxiety significantly contribute to these finding amongst this
type of patients.
DISCUSSION
The research was focused on one of very topical issues, i.e. the metabolic syndrome and the
related psychic anxiety disorders and depression and on the assessment of quality of life
amongst patients with the disease. The research findings show that there is a significant
difference in the anxiety rate between the research group of patients with MS and the control
group. Due to the array of risk factors, the patients with MS show increased anxiety. These
results are confirmed by a study carried out in Australia (Lambert et al., 2010, p. 543 - 550).
These findings correspond to a survey conducted in the USA, confirming a significant
correlation between psychiatric symptoms – depression, anxiety – and the total body fat.
(Guedes et al., 2013, p. 1 - 11). As well as anxiety, depression is in focus as a trigger factor of
the metabolic syndrome. This was the topic of a Finnish longitudinal study, which noted that
women with depression symptoms are at 2.5times higher risk of developing metabolic
syndrome than women without these symptoms (Vanhala et al., 2009, p. 137 - 142). A survey
conducted by Marijnissen et al. amongst 1277 individuals with metabolic syndrome shows
that people with MS have a significantly higher depression score measured with BDI in
comparison to the control group (Marijnissen et al., 2013). These above mentioned results
correspond to the findings of our research, which clearly indicate a significantly higher
depression rate in the research group.
259
Another aim of the study was to ascertain quality of life amongst people with MS. We
assumed that there is a significant difference in the degree of quality of life between the
research sample and the control group. This assumption was based on an Iraqi study, which
found out that people with MS have a significantly lower quality of life, especially in the
domain of physical health, social relationships and psychic health in general (Roohafza et al.,
2012, p. 1 - 6). In their study, Miettola et al. confirm statistically significant differences
between individuals with MS and individuals without MS in areas of mobility, quality of
hearing, breathing, ADL’s, discomfort, vitality and sex life.
The conclusions also confirmed that mitigation of the symptoms of the metabolic syndrome
leads to improved quality of life (Miettola et al., 2005, p. 1055 - 1062). These finding
correspond to the results of our study. Individuals with MS have significantly lower quality of
life in comparison to the control group. At the same time, a significantly higher depression
and anxiety rates were ascertained, which lead to significantly lower quality of life. The
central question is whether quality of life amongst these individuals is lower due to the MS
itself or due to the depression and anxiety which are concurrently present in abundance. These
causal relations will be the goals of further investigation.
CONCLUSION
The acquired results may be of great benefit, because the psychic side of MS is currently
neglected to a large extent. Attention is almost exclusively paid to bodily comfort. The
nursing staff should not ignore that the MS might actually be caused by psychic disorders or
that psychic disorders might trigger the MS. This is where the holistic medicine should come
into play. The treatment of MS should not be only somatic (biological), but should also deal
with the patient’s psyche (psychological intervention).
The treatment of psychic problems might significantly contribute to the complex treatment of
the metabolic syndrome.
The article is dedicated to the project Student Grant Competition Palacky University in
Olomouc: Environmental motivating factors in general nurses working in the university
hospitals in Olomouc and Prague (FZV_2014_009).
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CONTACT AN AUTHOR
Mgr. Šárka Vévodová, Ph.D.
Department of Humanities and Social Sciences, Faculty of Health Sciences, Palacký
University in Olomouc
Tř. Svobody 8, Olomouc 771 11, Czech Republic, Europe
e-mail: [email protected]
262
ATTENDANCE OF THE PUBLIC IN THE PREVENTION OF
COLORECTAL CANCER
Virgulová Jana, Frčová Beáta, Šupínová Mária, Janiczeková Elena
Faculty of Health, Slovak Medical University in Bratislava with the residence in Banská
Bystrica
ABSTRACT
Background: This study examines a sample group of inhabitants and their participation in the
screening for colorectal cancer.
Methods: Quantitative research method - a questionnaire survey. 2,000 questionnaires were
analyzed. The respondents of the survey were men and women aged over 50 years (to whom
the screening of colorectal cancer primarily intended), from two regions of the Slovak
Republic, which is statistically confirmed by the highest and lowest rate of gross incidence of
colorectal cancer. Statistical elaboration was conducted using the inductive method of
Student's t-test for the independent samples.
Results: The interest of residents about preventive testing is generally rather weak, average
values are below 3 (2.87). The P-value of 0.819 indicates the compliance of mean values.
Conclusion: Based on the statistical research, it was noted that the difference in the
participation of the population of the two regions of Slovakia, with the highest and lowest
gross incidence of colorectal cancer, is not statistically significant, and it is claimed that there
is no link between the gross rate of the incidence of colorectal cancer and participation of the
population in its prevention.
Key Words: colorectal cancer, prevention, health, research.
INTRODUCTION
In Slovakia, malignant colorectal tumours are the second leading cause of death in the
population of malignant tumours. The group with the highest risk of colorectal cancer is those
around 60 years of age (Hlava, 2010). From the year 2002, various stages of colorectal cancer
screening to eliminate malignant colorectal tumours, took place across Slovakia. A pre-study
in 2009, gave great feedback from the public showing a willingness to participate in
colorectal cancer screening. More than eighty-thousand people signed up to the screening
263
process. However, the question remains why tests to assess the result were returned only by
half of test willing individuals (Hrčka, 2010 / a).
The main objective of the research was to determine whether “a relationship exists between
the interest of the population of selected regions of Slovakia on colorectal cancer screening,
and the rate of its gross incidence”?
Hypotheses set:
Does a relationship exist between the amount of the gross incidence of colorectal cancer and
the rate of public acceptance of this screening?
We assume that a relationship exists between the gross incidence of colorectal cancer and the
level of public attendance for its screening.
We assume that a relationship exists between gender and the level of interest in the screening
of colorectal cancer.
METHODS
A structured questionnaire, in which respondents were asked twenty-six questions, was used
as the method for collecting empirical data. Each question was measured by a 5° interval
range, examining the values of quantity (not at all - maximum), capacity (not at all - fully),
frequency (never - ever), rating (very dissatisfied - very satisfied), and quality (very bad - very
good). Prior to completing the questionnaire, an introductory conversation about the purpose
of the research was between the researcher and the respondent. To interview the intended
number of two-thousand participants, a research group of 50 research assistants, comprising
of professional nurses studying the external master study programme at the Faculty of Health,
Slovak Medical University, Bratislava, with the residence in Banská Bystrica, was formed.
Interviews were completed in medical facilities, clinics and ambulance waiting rooms. Data
collection was undertaken from September 2012 through to September 2013. From the
respondent population we created two samples. Sample A, with 1,000 respondents, was
formed from residents of the Nitra region, where the highest incidence rate of colorectal
cancer is recorded. Sample B, with 1,000 respondents, was formed from residents of the
Prešov region, where the lowest incidence rate of colorectal cancer was recorded. The
condition for the selection of research participants, comprising both male and female, age 50
and over was because colorectal cancer screening is primarily intended for this demographic
of the Slovak population. The data from the questionnaires was integrated into the
264
contingency table collectively, as well as for each result individually. Both descriptive and
inductive statistical methods were used for data analysis. The Student’s t-test was used to
verify the hypothesis by testing the difference between the arithmetic averages of the two
groups. A significance level of α = 0.05 was implemented in all calculations. If the p-value
outcome was very low, a comparison was made at all levels of significance.
RESULTS
There was a 100 % return of questionnaires. Of the total responses, 36 % of respondents were
in the ‘up to 55 years’ group. A smaller proportion of 25 % of respondents were in the '56 to
60 years’ group. 18 % of respondents were in the ‘61-65 years’ group, 14 % were in the ‘6670 years’ group, and 7 % were in the ‘over 70 years’ group. With regards to gender, 53 % of
respondents were female and 47 % were male. 1,066 participants were urban residents whilst
934 were rural residents. 19 % of the respondents had primary education, 65 % of them had
secondary education and 16 % of residents had a university education.
In the first stage of the research attention was given to the attitude of respondents to
preventive examinations in general.
Table 1 Attitude to preventive examination
Possibilities
Rate
%
1
Very negative
49
2%
2
Negative
303
15 %
3
Indecisive
662
33 %
4
Positive
819
41 %
5
Together
Very positive
167
8%
2000
Mean value
100 %
3.38
Overall a positive attitude prevailed towards preventive examinations with a mean result of
3.38. However, results for a ‘positive’ and ‘very positive’ attitude combined constituted just
under half of the total responses. It was noted that there was not a significant difference
towards personal attitudes of preventive examinations among the populations of the
geographic regions.
In the second stage, we tested the null and alternative hypothesis to verify the connection of
the gross incidence of colorectal cancer with participation of the population for its prevention
in the chosen regions.
265
We assume that in the Nitra region, where incidence is highest, citizens have the same interest
in participation in the prevention of colorectal cancer as residents in the Prešov region where
incidence is lowest.
We assume that in the Nitra region, where incidence is highest, citizens have less interest in
participation in the prevention of colorectal cancer than residents in the Prešov region where
incidence is lowest.
The interest of the population in preventive examinations is, overall, rather weak. The average
scores of interest are below 3. Moreover, the p-value of 0.819 indicates compliance of the
mean values. Based on the statistical investigation, we concluded that the difference in the
level of participation of the inhabitants of the Prešov and Nitra regions in the prevention of
colorectal cancer is not statistically significant. There is no correlation between the incidence
rates of colorectal cancer and the interest of the inhabitants to participate in its prevention.
Table 2 Attendance in screening examinations of stool
Possibilities
1 – never
2 – sometimes
3 – quite often
4 – often
5 – steadily
Together
Mean value
Rate
324
386
689
434
167
2000
%
16 %
19 %
34 %
22 %
8%
100 %
2.87
Further, the participation of men and women in preventative check-ups in general, as well as
for the screening of colorectal cancer, was compared.
We assume that there is a relationship between gender and level of interest in colorectal
cancer screening.
We assume that women participate as equally in prevention as men.
We assume that women participate more in prevention than men.
Tale 3 PP based on gender
female
male
Together
Mean value
3.46
3.28
3.38
Variance
0.88
0.81
0.85
Number
1048
952
2000
p-value
2.4E-05
266
Women were shown to have a more active attitude towards undertaking preventive checks.
The results for both genders tend to a positive attitude however the mean value in the group of
women is about 0.18 higher. Based on the calculated p-value (2.4E-05) the difference is
statistically significant. In the actual screening of stool, the differences were also detected in
favour of women. The mean value for the interest of women in this particular examination is
2.98 and for men 2.74. The gender gap is greater than in the previous comparison. The
absolute value is equal to 0.24. The higher significance of the difference is confirmed by the
calculated p-value (5.9E-06). Based on the statistics gathered it can be concluded that women
have a more active approach to preventive examinations than men. This claim applies not
only to general prevention, but also in the active prevention of colorectal cancer.
Table 4 Examination of stool – based on gender
female
male
Together
Mean value
2.98
2.74
2.87
Variance
1.40
1.32
1.37
Number
1048
952
2000
p-value
5.9E-06
DISCUSSION
By analyzing the gathered data, we found that, in general, Slovak inhabitants neglect
preventive examinations. Participation in prevention was shown to be less than half of the
total respondents. The attitude of the Ministry of Health to this problematic level of
attendance at preventive examinations by the Slovak population was presented in an interview
for Pravda newspaper by a spokeswoman of the Ministry (Čižmáriková, 3/2013). This is
translated to: “The greatest interest is in preventive examinations by a dentist that are used by
more than 90 % of Slovaks, followed by preventive gynaecological examinations, used by
only 43 % of female respondents and preventive checks by a general practitioners are used by
only 25 % ” (Hlavačková, 2013). The reasons for the lack of participation by the population in
preventative check-ups were given as, firstly that they feel healthy claimed by 63 % of men
and 44 % of women; secondly as a consequence of lack of time argued by 44 % of men and
27 % women; whilst other less common reasons were, for example: I do not think preventive
examinations reveal anything, it is a superficial examination; the examination is unpleasant; I
am afraid of the result; I’d prefer not to know the results (Hlavačková, 2013). In this research,
the rate of female satisfaction with health is shown to be somewhat higher 3.24 than the rate
267
of male satisfaction with health 3.19, but the difference is considered to be very small and
statistically insignificant, because the p-value is at 0.276. Alternatively, the differences in the
assessment of their own health between residents of Prešov and Nitra are quite significant.
The Prešov region obtained a mean value of 3.51 and Nitra region obtained a mean value of
2.92. The interest towards preventive examinations of stools, for the prevention of colorectal
cancer, among respondents showed a moderately prevalent interest (34 % n 689). Our results
confirm the findings documented by Hrčka (2012 / b, p. 10). Despite the proven effectiveness
of screening for colorectal cancer, nowhere in the world has the vulnerable population been
persuaded to participate in screening to the extent that a significant reduction in incidence and
mortality on the national scale could be achieved. Farands (in Hrčka, 2010 / a), found that the
demographic of lowest cooperation was those aged over 70 years, female, and of a low social
status. In our research, it was found that a further factor against undertaking a test may be the
fear of the results, which was generally acknowledged by both men and women.
Through their research Jarošová (2011) and Pechová (2009) also confirmed that both men and
women over the age of 50 are as absent in fundamental preventive examinations as absent in
the examination of stool for occult blood. Skála (2008) argues that, in not only primary care,
should it be that cancer prevention is an essential part of every examination of the patient,
meaning not only to take into consideration the general nature of preventive examinations.
Hlinková and Nemcová (2010) argue that in addition to variables such as (age, ethnicity, and
socioeconomic status,...) it appears that individuality of gender is the major factor that
influences an individual to carry out preventive activities in the approach to their own health.
However, Hrčka (2012) states that in Slovakia, there is 54 % of women and 46 % men in the
age of 50 years. Despite the fact that there is 8 % more women than men and they are more
responsible to accessing the screening of KRC. In a pilot project in 2012, when the process of
screening and primary screening colonoscopy was introduced, it had greater participation of
men. This may explain why there is a higher occurrence of colorectal cancer, its precursors,
and findings of positive tests for occult blood, in men. Logically, therefore, there are more
men sent for colonoscopy screening than women.
In the promotion of the colorectal cancer screening, 49 % of the respondents in this research
would welcome the intervention of a family doctor. The status of a family doctor was known
mainly in the past, and was characterized by the family physician that was responsible for all
family members, from birth to death. An advantage was also considered to be that they would
268
have a more thorough overview of the family in both health and social circumstances. Today,
in Slovakia the first line of contact of educated medical specialists is focused specifically on
the treatment of children, adults, gynaecological diseases, or diseases of the teeth and oral
cavity. The ideal of a family physician, with regards to the allocated number of patients would
be considered as that perceived of the country/village doctor, where, in some circumstances,
have less than half the number of patients of their urban counterparts. This is also supported
by research findings (Bátovský 2009, Hrčka 2010/b, Van Roosbroeck 2012 Kaminski 2012
Wohll 2006 Kolligs 2012, Schoen 2012...), showing that although screening methods have
been available for many years, a major problem still remains, however, with regards to the
application of wider population programs. Linked to this is the idea, to which also tends
Premysl Fric (Hrčka in 2012/b), that one may consider the introduction of a legislative
obligation of regular screening examinations for the population at highest risk, with clearly
defined sanctions for failure to comply (Hrčka, 2012/b. p.11). Among the experts the idea is
promoted that if a person counts on the solidarity of society in the form of reimbursement of
the costs connected to treatment of cancer of the colon, then society should therefore require
from the individual his solidarity in the form of participation in the screening process.
Whether to introduce this particular type of sanction in the contemporary liberal society of
Slovakia, as the population at risk avoid screening examinations, is a matter of courage and
public discussion about where the freedom of individual ends and where the public interest of
the society begins, for which it is necessary to give up a part of the freedom of decision
making. It can be assumed however, that such a radical legislative tool would considerably
increase the acceptability of screening for colorectal cancer for a particular part of the
population. The cost of financial penalty set by legislation, or its real reach ability, would
remain questionable. However, as has been shown in the statistics of preventive examinations,
that if the population wants, they can actively mobilize their forces and undergo preventive
examinations, for example at the dentist (which are often costly treatments), or after a certain,
media wave, it will be necessary in order to achieve the objective of application of more
educational method focusing on attitudes component and strengthening of motivation to
change behaviour in relation to their own health (Nemcová, Hlinková, 2010).
269
CONCLUSION
The effectiveness of a program focusing on the health attitudes of the population with regards
to the prevention of colorectal cancer is demonstrably positive in the level of medical and
nursing and demonstrably negative in the level of laic.
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CONTACT AN AUTHOR
PhDr. Jana Virgulová
FZ SZU in Bratislava with the resicence in Banská Bystrica
Sládkovičova 21
974 05 Banská Bystrica
[email protected]
271
CONTACT WITH BEREAVED PERSONS IN NURSING PRACTICE
Zítková Marie, Grossová Klementová Renáta
Zítková, M.: Department of Nursing, Faculty of Medicine, Masaryk University, Brno
Grossová Klementová, R.: Department of Pulmonary Diseases and Tuberculosis, University
Hospital, Brno
ABSTRACT
Background: At the Phase 1 of the Project called “Methodology of the Contact of Nurses
with the Bereaved”, it was focused on obtaining information concerning individual aspects of
nurses´ contact with the bereaved at the University Hospital.
Methods: The following departments were included: the Clinic of Pulmonary Diseases and
TB (CPDT), the Internal Hematology and Oncology Clinic (IHOC), and the Clinic of Internal
Medicine, Geriatry and General Practice (CIGGP). The data were obtained by means of nonstandardized anonymous questionnaires containing 25 questions. The data obtained were
processed by means of descriptive statistic methods. The sample studied consisted of 105
respondents.
Results: The way of handing-over the personal things to the bereaved was perceived as
suitable by 60 % respondents, 36.2 % respondents evaluated it as unsuitable and 3.8 %
respondents gave no opinion. 37.9 % nurses found the environment unsuitable, 24.1 %
mentioned the lack of privacy, 17.2 % respondents perceived the lack of a quiet atmosphere
and the same number did not like the storing of things. 3.4 % mentioned the difficulty of the
situation for the bereaved. According to the statements, the content of the dialogue between
the nurses and the bereaved consists of the following: 7.6 % only deal with formal matters
and handover of the things, 28.6 % mention, in addition, a conversation, and 63.8 %
respondents give, in addition to the above mentioned, assistance and advice to the bereaved.
The average time spent on the formal matters was 14.9 minutes (median 15, minimum 2 and
maximum 60 minutes). The time spent on the subsequent conversation was found to be, on
average, 8.75 minutes (median – 5, minimum – 0, maximum – 30 minutes). During the
statistic testing, the relationship between the perceived sufficiency of nurses´ knowledge and
the stated easiness of communication with patients was confirmed (p=0.003).
272
Conclusions: Currently, the nursing staff is not systematically trained in the communication
with the bereaved. The introduction of a systematic nursing education is focused on the
improvement of their communication skills which will have impact on the higher quality of
care of the bereaved in the University Hospital. This Project is supported by Ministry of
Health, Czech Republic – conceptual development of research organization (FNBr,
65269705).
Key Words: the bereaved, nursing practice, communication, education, quality of care.
INTRODUCTION:
The contact with the bereaved is a very demanding area of work of health care staff. It is
known that the last time which the nurses devote to the bereaved and particularly the way in
which they communicate, their attentiveness and tact, and the offer of help are factors
according which the quality of all medical and nursing care is evaluated. The place where the
dialogue takes place and the time reserved for the conversation also play their role. Naturally,
mature conversation based on sufficient knowledge and skills is, above all, the basis of an
effective contact on the part of nurses. In the setting of a health care facility, where there is
only limited time and possibilities to establish a contact with the bereaved, the dynamics of
the behavior must be more used, the signals of pathological mourning must be perceived and
identified in the process of mourning or another impact of the situation or the nurses´
behavior on clients must be identified.
The contact with the bereaved represents a very specific area of nursing activities. It can be
implemented at a general or a professional level. The general level of assistance is, at a
particular professional, characterized by suitable psychological properties, experience,
empathy and prestige; the professional level is enriched by sufficient formal education in
particular problems (Špaténková, 2013, p. 38-39). The help for the bereaved includes a
comparatively wide range of activities, from the above mentioned general approaches to
professional approaches, i.e. from compassionate and empathic help to the intervention in
crisis, counseling or psychiatric help. Juřeníková emphasizes that nurses fulfill the role of
aknowledge and experience provider, they are advisors and supporters at the same time
(Juřeníková, 2010, p. 65).
While planning the structure and organization of the information which is announced to the
bereaved, individual differences of perception of the situation among the individuals – age,
273
health condition, education, beliefs, religion, and also their topical emotional condition -must
be taken into account. Therefore, when meeting the bereaved, the information must be simple,
easily understandable and well structured (Vymětal, 2009, p. 123). Both verbal and nonverbal
communications are important for the context of the communication, i.e. for its wider
associations and properties (DeVito, 2008, p. 34).
Within the Phase 1 of the Project called the Methodology of the Contact of Nursing Staff with
the bereaved, it focused was on getting the information on individual aspects of the contact of
nurses and the bereaved in the University Hospital. This phase is followed by other planned
activities aiming at the development of competences of providing professionals help to the
bereaved.
METHODS
This investigation was performed between November and December, 2013. The contact
departments included the Clinic of Pulmonary Diseases and TB, Internal Hematologic and
Oncology Clinic and the Clinic of Internal Medicine, Geriatry and General Medicine. The
data were obtained by means of an anonymous non-standardized questionnaire containing 25
questions which was developed in accordance with the Project. The data obtained were
processed by means of descriptive statistic methods. The tests used were chosen according to
the character of the data, the level of the significance was set to be 0.05. The sample studied
consisted of 105 respondents (100 %). 4 respondents were excluded from the sample because
they stated that they had not had any experience with the handover of the deceased persons´
things to the bereaved. The rate of the questionnaire return was 73.2 %.
RESULTS
The largest group of respondents – 61 (58.2 %) was employed by IHOK, followed by 30
respondents (28.5 %) from KNPT and 14 (13.3 %) respondents were employed by KIGOPL.
The category of employees taking part in handing over the personal things to the bereaved
includes: general nurses or nursing aids – 93 (88.6 %), the participation of medical orderlies
was mentioned by 9 (8.6 %) respondents, and 3 (2.8 %) respondents mentioned the
cooperation with the doctor. The way of handing over the personal things to the bereaved is
found to be suitable by 63 (60 % (n=105) respondents, 38 (36.2 % (n=105) evaluate it as
unsuitable and 4 (3.8 % (n=105) did not mention the perceived suitability. The respondents
had the chance of more options to give the unsuitability of the way of handover. 11 (37.9 %
274
(n=29) find the setting unsuitable, 7 respondents (24.1 % (n=29) mention the lack of privacy,
and 5 (17.3 % (n=29) persons find the lack of a quiet atmosphere and 5 (17.3 % (n=29) find
the storing of the personal things unsuitable. One respondent (3.4 %, (n=29) mentions the
difficulty of the situation for the bereaved. The handover itself takes place in a free room at
the department in 58 (55.3 %) nurses, and in the office of nurses in 23 (21.9 %) nurses, in the
department corridor in 18 (17.1 %) respondents and 6 (5.7 %) respondents mention the
farewell room. The personal things of the deceased are handed over in a transparent plastic
bag in 69 (65.7 %) respondents, .in a non-transparent plastic bag in 30 (28.6 %) respondents,
and more options were mentioned by 6 (5.7 %) respondents. The content of the dialogue
between nurses and the bereaved consists, in the opinion of the respondents, of the following:
8 respondents (7.6 %) only deal with formal matters and the handover of the personal things,
30 (28.6 %) respondents mention, in addition, a conversation and the largest group, 67 (63.8
%) respondents mention, in addition to the above mentioned aspects, the assistance and
advice to the bereaved. The way of providing the information is a written and an oral form in
83 (79.9 %) cases and only an oral form in 21 (20 %) cases. 1 respondent (1 %) mentioned
only the written form.
7.6%
28.6%
Formal matters - handover of
personal things
Formal matters – handover of
personal things, dialogue
Formal matters – handover of
personal things and advice
63.8%
Figure 1 Content of the Dialogue
For the most frequent questions that the respondents were asked, there was the possibility of
more answers (n=209). The overview of the results is given in the following Table.
275
Within the investigation, the respondents were asked to state which facts were perceived as
difficult. The most frequent answers included the fact that the valuables of the deceased
person was not handed over at the department 27 respondents (25 % (n=108), the perceived
difficulty associated with the handover of the regulation fee was felt by 22 (25 % (n=108)
respondents. The most difficult problem of the contact is considered to be the reaction of the
bereaved – crying, anger, improper behavior by 52 (48.2 % (n=108) nurses. 7 (6.5 % (n=108)
responders mentioned the option “others”. The question which bereaved persons´ reactions
are encountered the most frequently in practice could be answered by multiple options. The
most frequent reactions are crying and sobbing 95 (44.2 % (n=215), apathy 43 (20 % (n=215)
and anger 32 (14.9 % (n=215). The other reactions included the fear and panic 25 (11.6 %
(n=215), the feeling of being guilty 14 cases (16.5 % (n=215) and others 6 (2.8 % (n=215).
Table 1 The most frequent questions
Absolute
frequency
90
49
31
23
9
7
How to arrange the funeral
The course of dying
Where are the valuables
Where is the body of the deceased person
When and where will I be given the death certificate
Will there be an autopsy
Summary
209
Relative
frequency
43.0 %
23.4 %
14.8 %
11.0 %
4.3 %
3.3 %
100,0 %
Table 2 Reactions of the bereaved
Crying, sobbing
Apathy
Anger
Fear or panic
Feeling guilty
Others
Summary
Absolute frequency
95
43
32
25
14
6
215
Relative frequency
44.2 %
20.0 %
14.9 %
11.6 %
6.5 %
2.8 %
100,0 %
The respondents had also the chance to identify their personal reactions and to make use of
multiple answers. The most frequent answer was: “I feel sorry but I don´t show my feelings”
53 answers (44.5 % (n=119). The reaction “I feel sorry but I don´t like the reaction of the
bereaved” was given in 44 (37 % (n=119) answers. 15 answers (12.6 % (n=119) related to the
reaction: “I don´t show emotions, I´m a professional”. The options “I am afraid of the
bereaved persons´ reaction” and “I avoid doing these tasks” were recorded in 3 (2.5 %
(n=119) respondents. The option of “others” was chosen by 4 (3.4 % (n=119) respondents.
The average time devoted to the formal matters of the contact with the bereaved was found to
276
be 14.9 minutes (median – 15 minutes, min. 2, max. – 60 minutes). The time spent on the
subsequent conversation was found to be on average of 8.75 minutes (median – 5, min. – 0,
max. – 30 minutes). The readiness of particular departments to face open emotional reactions
of the bereaved was evaluated by “yes” by 78 (74.3 %) respondents, it meant that a tissue or
a glass of water were offered. 14 (13.3 %) nurses chose the option “no” , “I have no
possibilities and tools”. 5 (4.8 %) stated that it was not necessary , 6 (5.7 %) chose the option
“others” and 2 (1.9 %) respondents did not answer. 57 (54.3 % ) respondents evaluated the
knowledge of these problems as sufficient, 44 (41.9 %) evaluated it as insufficient and 4 (3.8
%) respondents did not know. For the knowledge problem concerning the description of the
concept of complicated mourning, 29 (27.6 %) correct questions were obtained, 9 (8.6 %)
questions were partially correct and the most, 57 (54.3 %) questions were incorrect. 10 (9.5
%) respondents did not answer this question. 58 (55.3 %) respondents state that the personal
skills in communication with the bereaved are sufficient, 41 (39 %) found them insufficient
and 6 (5.7 %) respondents did not answer. The most frequent proposals for the help to the
bereaved included educational material 16 (20.3 % (n=79), establishing the post of an advisor
for the bereaved 15 (19.0 % (n=79), a convenient room for the bereaved 15 (19.0 % (n=79),
and a suitable place for handing over the personal things 14 (17.6 % (n=79). The possibility of
a psychological support was mentioned by 8 (10.1 %, n=79) respondents and 4 respondents
(5.1 % (n=79) stated that more time would be an improvement.
After statistic processing, the influence of the place of the handover of personal things on the
length of the contact between nurses and the bereaved was tested. According to the results
(p=0,092), this influence was not confirmed. The highest mean value in Kruskall-Wallis test
was achieved in a conversation held in a free room at the department, which demonstrates the
fact that these conversations take a longer time than conversations held in the nurses´ room or
in the corridor. The statistic testing proved the relationship between the perceived sufficiency
of nurses´ knowledge and the easiness of communication with the bereaved significant ones
of patients who had been hospitalized for a long, medium and long time (p=0.003). 38 (65.2
% (n=58) respondents mentioned sufficient skills in communication with the bereaved of
patients with short term hospitalization, 14 (24.5 % (n=58) in the case of patients with
hospitalization of medium length, and only 6 (42.1 % (n=58) respondents mentioned
sufficient skills with the SOs of patients who had been hospitalized for a long time. On the
other hand, the insufficiency of communication with the bereaved was expressed by 16 (42.1
% (n=38) respondents in the case of patients with long-term hospitalization, 5 (13.2 % (n=38)
277
in patients with hospitalization of medium length, and 17 (44.7 % (n=38) in patients with a
short-term hospitalization.
120
100
44,7
80
Insufficient skills
60
Sufficient skills
40
65,2
20
42,1
13,2
24,5
10,3
0
Short time, days
Weeks, repeated
Months repeated
Figure 2 Perceived sufficiency of skills versus the length of the patient´s hospitalization.
DISCUSSION
The main goal of the investigation was to identify the context of the contact between nurses
and the bereaved at the University Hospital. The way of the handover of personal things to the
bereaved is perceived as suitable only by 60 % respondents. The most shortcomings stated
included unsuitable setting, lack of privacy, lack of quiet atmosphere and unsuitable storing
the personal things. Unfortunately, in none of the departments, special bags were used for
storing of personal things of the deceased, only transparent or opaque plastic bags were used.
The main arguments for using these inconvenient containers are economical reasons. Within
this Project, special bags were provided for storing personal things. The setting was also
mentioned by 37.9 % respondents as a shortcoming of the practice. No statistically significant
relationship between the length of the conversation and the place where it was implemented
was identified (p=0.092). In general, it can be said that the longest conversations take place in
a free room of the department compared with the nurses´ room and the corridor. The
conversation in a free room also meets other criteria, particularly for ensuring the quiet and
private atmosphere (Ptáček, Bartůněk, 2011, p. 62-68). The subjective feeling of time press
can also influence the course of the conversation in a significant way (Špaténková, Králová,
2010, p. 9). During our investigation, our respondents spent, on average, 23.7 minutes on
talking with the bereaved. Valeriánová mentions in her investigation that the time
278
recommended for communication by 56.9 % respondents is 30 minutes (Valeriánová, 2012, p.
57). The optimal length of dealing with the bereaved depends on many factors, both on the
part of nurses and the bereaved. The form of the report (announcement) should be
structuralized and designed in a way to enable the information which is important and easily
understandable (Vymětal, 2009, p. 123). The content of the conversation includes formal
maters concerning the awareness of organizing the funeral and handover of the personal
things. The informal part of the conversation relates to providing the SOs with information on
the course of dying, the possibilities of help to the bereaved and identification of protective
mechanisms and coping strategies for the bereaved. In our investigation, 63.8 % respondents
only mentioned this practice. The inseparable part of both parts of the communication is
listening to the bereaved, observing their emotions, both verbal and nonverbal expressions or
moments of silence (Sláma, and all., 2007, p. 317). This finding enables a significant
possibility to improve the nurses´ readiness resulting in a higher quality of care. The
respondents´ proposals for a higher quality of care concerned both printed educational
materials in 20.3 % and room adaptations, particularly creating some space for the bereaved
and the handover of the personal things in 17.7 %. 19 % respondents regard the establishment
of an advisor for the bereaved as an improvement of the level of the quality of the care of the
bereaved.
The perceived personal readiness, i.e. the area of knowledge and skills, proved to be essential
for the communication with the bereaved. The communication takes place in the context of a
physical, cultural, social and psychological and time setting, which, to a significant degree,
determines the significance of each verbal and nonverbal message. Therefore, personal
maturity and experience are a precondition for a high-quality communication (DeVito, 2008,
p. 34). As further possibilities to improve the readiness, theoretical seminars and practical
training are proposed. This requirement is confirmed in the investigation by Savarová
(Savarová, 2013, p. 47). In the investigation of 30 respondents, Marková states that 74 %
respondents encountered death as late as in the third year of their qualification study
(Marková, 2010, p. 30). This information only underlines the necessity of a structured further
education of health care staff after starting the professional practice, and the necessity of
active handover of experience and skills.
While testing the relationship between the perceived sufficiency of skills in the
communication with the bereaved and the length of the hospitalization of the deceased
279
patient, it turned out that the best skills are perceived in the case of the communication with
the families of patients who had been hospitalized for a short time and the worst skills in the
case of patients who had been hospitalized for a long time (p=0.003). It can be supposed that
a long-term relationship with the patient followed by the communication with the bereaved is
the most demanding for nurses. This finding again underlines the necessity of nurses´
systematic education and training.
CONCLUSION
The goal of the investigation was to identify the basic aspects of nurses´ contact with
bereaved in the setting of the University Hospital. Based on the results identified, it was
possible to determine the basic trends of further improvement of the nurses´ readiness for this
demanding part of their profession. Currently, the nursing staff is not systematically trained in
the communication with the bereaved and the basic structure including all aspects of
communication with the bereaved has not been created. The introduction of a systematic
nurses ´ education related with these problems sets a goal to improve communication skills in
order to increase the quality of care of the bereaved in the University Hospital. This Project is
supported by Ministry of Health, Czech Republic – conceptual development of research
organization (FNBr, 65269705).
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CONTACT AN AUTHOR
PhDr. Marie Zítková
Department of Nursing, Faculty of Medicine, Masaryk University, Kamenice 3, Brno 625 00,
Czech Republic, Europe
e-mail: [email protected]
281
International Symposium: Sience and Research in Nursing
26th September 2014. Conference Proceedings
Edited by:
MSc. Alena Pospisilova, Ph.D.
MSc. Petra Jurenikova, Ph.D.
Reviewed by:
doc. PhDr. Andrea Pokorna, Ph.D.
MSc. Simona Saibertova
MSc. Jana Strakova, Ph.D.
PhDr. Marie Zitkova
Published by Masaryk University, Brno 2014
First edition
Print run 100 copies
Number of pages: 281
ISBN 978-80-7013-574-7
282