Ingles - 26(2).indb

Transcription

Ingles - 26(2).indb

Official Organization for Scientific Dissemination of the Escola
Paulista de Enfermagem, Universidade Federal de São Paulo
Acta Paulista de Enfermagem/ Escola Paulista de Enfermagem/ Universidade Federal de São Paulo
Address: Rua Diogo de Faria, 1087, 6th Floor - 601, Vila Clementino, São Paulo, SP, Brazil. Zip Code 04037-003
Acta Paul Enferm. v.26, issue(2), March/April 2013
ISSN: 1982-0194 (electronic version)
Frequency: Bimonthly
Phone: +55 11 5082-3287
E-mail: [email protected]
Home Page: http://www.unifesp.br/acta/
Facebook: facebook.com/ActaPaulEnferm
Twitter: @ActaPaulEnferm
Tumblr: actapaulenferm.tumblr.com
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Editorial Council
President
Lucila Amaral Carneiro Vianna
Acta Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Chief Editor
Sonia Maria Oliveira de Barros
Technical Editor
Edna Terezinha Rother
Associate Editors
Department of Administration and Public Health
Elena Bohomol, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Elisabeth Niglio de Figueiredo, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Department of Medical and Surgical Nursing
Bartira de Aguiar Roza, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Edvane Birelo Lopes De Domenico, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
João Fernando Marcolan, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Ruth Ester Assayag Batista, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Department of Pediatric Nursing
Ariane Ferreira Machado Avelar, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Maria Magda Ferreira Gomes Balieiro, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Department of Women’s Health Nursing
Erika de Sá Vieira Abuchaim, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Rosely Erlach Goldman, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil
Editorial Board
National
Alacoque Lorenzini Erdmann, Universidade Federal de Santa Catarina-UFSC, Florianópolis-SC, Brazil
Ana Cristina Freitas de Vilhena Abrão, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Cibele Andrucioli de Matos Pimenta, Escola de Enfermagem da Universidade de São Paulo-EE/USP, São Paulo-SP, Brazil
Circéa Amália Ribeiro, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Conceição Vieira da Silva-Ohara, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Elucir Gir, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Emília Campos de Carvalho, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Isabel Amélia Costa Mendes, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Isabel Cristina Kowal Olm Cunha, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Ivone Evangelista Cabral, Escola de Enfermagem Anna Nery- EEAN/UFRJ, Rio de Janeiro-RJ, Brazil
Janine Schirmer, Universidade Federal de São Paulo-USP, São Paulo-SP, Brazil
Josete Luzia Leite, Escola de Enfermagem Anna Nery - EEAN/UFRJ, Rio de Janeiro-RJ, Brazil
Lorita Marlena Freitag Pagliuca, Universidade Federal do Ceará-UFC, Fortaleza-CE, Brazil
I
Lúcia Hisako Takase Gonçalves, Universidade Federal de Santa Catarina-UFSC, Florianópolis-SC, Brazil
Margareth Ângelo, Universidade de São Paulo-USP, São Paulo-SP, Brazil
Margarita Antônia Villar Luís, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Maria Antonieta Rubio Tyrrel, Escola de Enfermagem Anna Nery- EEAN/UFRJ, Rio de Janeiro-RJ, Brazil
Maria Gaby Rivero Gutiérrez, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Maria Helena Costa Amorim, Universidade Federal do Espírito Santo-UFES, Vitória-ES, Brazil
Maria Helena Lenardt, Universidade Federal do Paraná-UFP, Curitiba-PR, Brazil
Maria Helena Palucci Marziale, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Maria Júlia Paes da Silva, Universidade de São Paulo-USP, São Paulo-SP, Brazil
Maria Márcia Bachion, Universidade Federal de Goiás-UFG, Goiânia-GO, Brazil
Maria Miriam Lima da Nóbrega, Universidade Federal da Paraíba-UFPB, João Pessoa-PB, Brazil
Mariana Fernandes de Souza, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Mavilde da Luz Gonçalves Pedreira, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil
Paulina Kurcgant, Universidade de São Paulo-USP, São Paulo-SP, Brazil
Raquel Rapone Gaidzinski, Universidade de São Paulo-USP, São Paulo-SP, Brazil
Rosalina Aparecida Partezani Rodrigues, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Silvia Helena De Bortoli Cassiani, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil
Telma Ribeiro Garcia, Universidade Federal da Paraíba-UFPB, João Pessoa-PB, Brazil
Valéria Lerch Garcia, Universidade Federal do Rio Grande-UFRGS, Rio Grande-RS, Brazil
International
Barbara Bates, University of Pennsylvania School of Nursing - Philadelphia, Pennsylvania, USA
Donna K. Hathaway, The University of Tennessee Health Science Center College of Nursing; Memphis, Tennessee, USA
Dorothy A. Jones, Boston College, Chestnut Hill, MA, USA
Ester Christine Gallegos-Cabriales, Universidad Autónomo de Nuevo León, Monterrey, Mexico
Geraldyne Lyte, University of Manchester, Manchester, United Kingdom, USA
Helen M. Castillo, College of Health and Human Development, California State University, Northbridge, California, USA
Jane Brokel, The University of Iowa, Iowa, USA
Joanne McCloskey Dotcherman, The University of Iowa, Iowa, USA
Kay Avant, University of Texas, Austin, Texas, USA
Luz Angelica Muñoz Gonzales, Universidad Nacional Andrés Bello, Santiago, Chile
Margaret Lunney, Staten Island University, Staten Island, New York, USA
María Consuelo Castrillón Agudelo, Universidad de Antioquia, Medellín, Colombia
Maria Müller Staub, Institute of Nursing, ZHAW University, Winterthur, Switzerland
Martha Curley, Children Hospital Boston, Boston, New York, USA
Patricia Marck, University of Alberta Faculty of Nursing, Edmonton Alberta, Canada
Shigemi Kamitsuru, Shigemi Kamitsuru, Kangolabo, Tokyo, Japan
Sue Ann P. Moorhead, The University of Iowa, Iowa, USA
Tracy Heather Herdman, Boston College, Massachusetts, USA
Editorial Office
Bruno Henrique Sena Ferreira
Danilo Douglas Ferreira
Maria Aparecida Nascimento
Graphic Design
Adriano Aguina
Acta Paulista de Enfermagem – (Acta Paul Enferm.), has as its mission the dissemination of scientific knowledge
generated in the rigor of the methodology, research and ethics. The objective of this Journal is to publish original research
results to advance the practice of clinical, surgical, management, education, research and health informatics in nursing.
Member of the Brazilian Association of Scientific Editors
II
Universidade Federal de São Paulo
President of the Universidade Federal de São Paulo
Soraya Soubhi Smaili
Vice-President of the Universidade Federal de São Paulo
Valeria Petri
Dean of the Escola Paulista de Enfermagem
Lucila Amaral Carneiro Vianna
Vice-Dean of the Escola Paulista de Enfermagem
Departments of the Escola Paulista de Enfermagem
Administration and Public Health
Isabel Cristina Kowal Olm Cunha
Medical and Surgical Nursing
Solange Diccini
Pediatric Nursing
Myriam Aparecida Mandetta
Women’s Health Nursing
Ana Cristina Freitas Vilhena Abrão
Undergraduate Program
Suzete Maria Fustinoni
Extension
Postgraduate
Isabel Cristina Kowal Olm Cunha
Completion
Support
All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License.
With a view tward sustainability and accessibility, Acta Paulista de Enfermagem is published exclusively in the digital format.
III
Editorial
R
eflecting upon what we are commemorating on “Nurses’ Day 2013”
is a thought-provoking question. The date of May 12 is internationally considered to be the “day of the nurse,” by the “International
Council of Nurses.” In Brazil we commemorate Nurses’ Week instituted by
Decree No. 48.202 of May 12, 1960, awarded by the Brazilian President,
Juscelino Kubitschek, which established a “nurses’ week” in honor of, respectively, the birth of Florence Nightingale on May 12, 1820 and, the death
of Anna Nery on May 20, 1880.
Throughout history, Brazilian nursing has been stimulated by several
issues, including: neoliberal policies, capital interests and dominant social
classes; the search to numerically expand its staff of professionals. Nursing,
grounded in a dominant discourse, pointed out that it was necessary to
increase the number of professionals so that we could improve the performance and representativeness of nursing in Brazil. Calculated upon this
ideology, we arrived to the numbers of today.
In April of 2013 we totaled 403,000 nursing professionals, registered
in the State of São Paulo, and 90,000 of these were nurses; in 2010 we had
73,000 nurses . At the moment the number of technicians and nursing assistants in the state totals 310,000 professionals. In three years, 20,000 nurses graduated in the state of São Paulo. What do these numbers represent
to the increase in quality professional practice?
This year the theme of the 74th Brazilian Nurses’ Week, promoted by
the Brazilian Nursing Association (ABEn), deals with the theme: “Professional consciousness and nursing in life care. “
Seeking a balanced relationship between the framework for training
from the qualitative and quantitative standpoint, it is proposed that we
should promote the “nurses’ weeks” to come. In this process we will diminish errors, we will improve the professional conscientiousness, and without
any doubt, the care of the human life, the biggest inspiration of nursing
professionals.
Mauro Antônio Pires Dias da Silva
President of the Regional Council of Nursing (COREN) - São Paulo
IV
Contents
Original Articles
Documentation system prototype for postpartum nursing
Protótipo de sistema de documentação em enfermagem no puerpério
Regina Célia Sales Santos Veríssimo, Heimar de Fátima Marin�� 108
Nursing workload in the post-anesthesia care unit
Carga de trabalho de enfermagem em unidade de recuperação pós-anestésica
Luciana Bjorklund de Lima, Eneida Rejane Rabelo�� 116
Concurrent Validation of Nursing Scores (NEMS and
TISS-28) in pediatric intensive care
Validação Concorrente de Escores de Enfermagem (NEMS e TISS-28) em terapia intensiva pediátrica
Simone Travi Canabarro, Kelly Dayane Stochero Velozo, Olga Rosária Eidt,
Jefferson Pedro Piva, Pedro Celiny Ramos Garcia�� 123
Maternal age and factors associated with perinatal outcomes
Idade materna e fatores associados a resultados perinatais
Angela Andréia França Gravena, Meliana Gisleine de Paula, Sonia Silva Marcon,
Maria Dalva Barros de Carvalho, Sandra Marisa Pelloso�� 130
Challenges for the management of emergency
care from the perspective of nurses
Desafios para a gerência do cuidado em emergência na perspectiva de enfermeiros
José Luís Guedes dos Santos, Maria Alice Dias da Silva Lima, Aline Lima Pestana,
Estela Regina Garlet, Alacoque Lorenzini Erdmann................................................................................................................136
Construction and validation of an instrument for
classification of pediatric patients
Construção e validação de um instrumento de classificação de pacientes pediátricos
Ariane Polidoro Dini, Edinêis de Brito Guirardello�� 144
Prevalence of drug interactions in intensive care units in Brazil
Prevalência de interações medicamentosas em unidades de terapia intensiva no Brasil
Rhanna Emanuela Fontenele Lima de Carvalho, Adriano Max Moreira Reis, Leila Márcia Pereira de Faria, Karine Santana de
Azevedo Zago, Silvia Helena De Bortoli Cassiani�� 150
Vertical transmission of HIV in the population treated at a reference center
Transmissão vertical do HIV em população atendida no serviço de referência
Sueli Teresinha Cruz Rodrigues, Maria José Rodrigues Vaz, Sonia Maria Oliveira Barros �� 158
Perceptions and expectations of nurses concerning their professional activity
Percepções e expectativas dos enfermeiros sobre sua atuação profissional
Augusto Hernán Ferreira Umpiérrez, Miriam Aparecida Barbosa Merighi, Luz Angélica Muñoz�� 165
Social representations of nurses about tuberculosis patients
Representações sociais de enfermeiros sobre o portador de tuberculose
Ivaneide Leal Ataíde Rodrigues, Maria Catarina Salvador da Motta, Márcia de Assunção Ferreira�� 172
V
Effectiveness of education in health in the nonmedication treatment of arterial hypertension
Eficácia da educação em saúde no tratamento não medicamentoso da hipertensão arterial
Thatiane Lopes Oliveira, Leonardo de Paula Miranda, Patrícia de Sousa Fernandes, Antônio Prates Caldeira �� 179
Infection or colonization with resistant microorganisms:
identification of predictors
Infecção ou colonização por micro-organismos resistentes: identificação de preditores
Graciana Maria de Moraes, Frederico Molina Cohrs, Ruth Ester Assayag Batista, Renato Satovschi Grinbaum�� 185
Organizational safety climate and adherence to
standard precautions among dentists
Clima de segurança organizacional e a adesão às precauções padrão entre dentistas
Patrícia Helena Vivan Ribeiro, Maria Meimei Brevidelli, Anaclara Ferreira Veiga Tipple,
Renata Perfeito Ribeiro, Elucir Gir�� 192
Expectations of the nursing staff in relation to the leadership
Expectativas da equipe de enfermagem em relação à liderança
Gisela Maria Schebella Souto de Moura, Juciane Aparecida Furlan Inchauspe, Clarice Maria Dall’Agnol,
Ana Maria Muller de Magalhães, Louíse Viecili Hoffmeister�� 198
Quality of life of patients with stroke rehabilitation
Qualidade de vida de pacientes com acidente vascular cerebral em reabilitação
Edja Solange Souza Rangel, Angélica Gonçalves Silva Belasco, Solange Diccini�� 205
VI
Original Article
Documentation system prototype
for postpartum nursing
Protótipo de sistema de documentação em enfermagem no puerpério
Regina Célia Sales Santos Veríssimo1
Heimar de Fátima Marin2
Keywords
Nursing informatics; Records systems;
Computerized, nursing process;
Postpartum period; Information
technology
Descritores
Informática em enfermagem; Sistemas
computadorizados de registros
médicos; Processos de enfermagem;
Período pós-parto; Tecnologia da
informação
Abstract
Objective: To develop a documentation system prototype for postpartum nursing.
Methods: For the software planning, a model based on object orientation was used, which included:
understanding and definition of the context and usage modes of the system design project, identification of the
main objects of the system, development of project models, specification of object interfaces. The languages
Structured Query Language (SQL), MySQL and Hypertext Preprocessor (php) were used.
Results: The prototype shows the planned requirements, among them: use of the International Classification
For Nursing Practice (ICNP®) version 1.0 as support code to perform the nursing process; presentation of the
axes of ICNP® version 1.0 in order of use; elaboration of reports about the usage practice of nursing processes.
Conclusion: The proposed documentation system prototype was successfully developed, allowing professional
nursing records to be registered in a standardized language.
Resumo
Submitted
May 16, 2011
Accepted
April 12, 2013
Corresponding author
Regina Célia Sales Santos Veríssimo
Lourival Melo Mota Avenue, s/n,
Tabuleiro dos Martins, Maceió, AL,
Brazil. Zip Code: 57072-900
[email protected]
108
Acta Paul Enferm. 2013; 26(2):108-15.
Objetivo: Desenvolver protótipo de sistema de documentação em enfermagem no puerpério.
Métodos: Planejamento de software utilizou modelo baseado em orientação a objetos, que englobou:
compreensão e definição do contexto e dos modos de utilização projeto de arquitetura do sistema, identificação
dos principais objetos do sistema, desenvolvimento dos modelos do projeto, especificação das interfaces dos
objetos. Foram utilizadas as linguagem Structured Query Language (SQL), MySQL e Hypertext Preprocessor
(php).
Resultados: O protótipo apresenta os requisitos planejados, entre eles: uso da Classificação Internacional
para a Prática de Enfermagem (CIPE®) versão 1.0 como código de apoio para execução do processo de
enfermagem; apresentação dos eixos da CIPE® versão 1.0 em ordem de uso; geração de relatórios sobre a
prática de uso dos processos de enfermagem.
Conclusão: O protótipo de sistema de documentação proposto foi desenvolvido com sucesso com possibilidade
de registros de enfermagem por meio de linguagem padronizada.
Universidade Federal de Alagoas, Maceió, AL, Brazil.
Universidade Federal de São Paulo, São Paulo, SP, Brazil.
Conflicts of interest: no conflicts of interest to declare.
1
2
Veríssimo RCSS, Marin HF
Introduction
Professional nursing practice is focused on care.
Caring for people necessarily requires that nursing
professionals use communication resources. Among
its various forms, communication among professionals may be a tool for successful nursing care.
And, in this context, nursing records stand out as
an important way of documented communication.
The clinical information nursing professionals
are faced with daily each time they meet with patients is numerous and valuable; however, the current process of obtaining and using this information produces a fragmented rather than synergistic
documentation and, as a consequence, its potential
to improve nursing care has not been explored.(1)
The records show the way professional nursing
practice is perceived and integrated by itself, by other healthcare professionals, by institutions’ payment
and audit systems and by the healthcare system, and
also serve as a parameter for clinical decision making and management.
The tasks of recording clinical data are varied
and complex. As the quantity of data and information in clinical practice increases, the volume and
levels of detail in nursing documentation also increase, without necessarily resulting in an improvement in the quality of information contents.(2)
The development of computer systems that
make record taking, use and analysis of clinical information easier promotes communication among
healthcare teams and contributes to the quality of
nursing care.
Nursing documentation systems are resources
used to make nursing record taking quicker and
more accurate, since they provide nursing and other
professionals with current and reliable information.
Using technological advances to plan the activities involved in patient care in a controlled and effective way is increasingly imperative, besides being
a requirement for nurses. Nurses want information
systems that reflect the reality of their clinical practice (tacit knowledge), but that can have elements
of formal knowledge (explicit), adapting them to an
automated system that covers the nursing process as
a whole.(3)
The nursing process serves as a systematic structure, in which nurses seek information about patients, respond to clinical instructions, identify and
respond to issues that affect patients’ health.(4) Therefore, it also serves as a work tool for nurses in relation
to data management, which need to be shared with
other members of the nursing and healthcare teams.
The system proposed by this prototype was
based on the nursing process practice and its stages. To record the information obtained through
its application, nurses use vocabulary and classification systems. Professional nursing practice
has sought to standardize its language in order
to support the communication among nursing
team members and also with other healthcare
professionals, thus seeking to facilitate the analysis and comparison of its expected outcomes, as
well as enabling the identification of its area of
knowledge.
Among the terminologies and classification systems, the ICNP® (International Classification of
Nursing Practice) is a very feasible option, since it has
noticeable linguistic, cognitive and technological advantages. The ICNP® is a classification system aimed
at standardizing the vocabulary used in professional
nursing practice, and a tool to value the nursing process. In print and digital formats for handheld computers, it can provide nurses with a shared language
for communication and analysis of the practice and
the overall progress of nursing care outcomes.(5)
The use of a standardized language in the development of care systems is an important progress and need for nurses, since it supports the construction of resources that assist the practice and
strengthen the practice field.(6) This context also
includes postpartum care. Midwives demonstrate
knowledge about the process in professional nursing practice, but point out factors that hinder or
prevent its use, such as lack of time, the large number of patients admitted to hospitals and the service turnover.(7) This prevents skilled nurses from
delivering efficient postpartum care to mothers
and children and makes them perform repetitive
activities, based on institutional routines that remain distant from the individual needs of women
during the postpartum period.
Acta Paul Enferm. 2013; 26(2):108-15.
109
The elaboration of this study was therefore justified, which is aimed at developing a documentation
system prototype for postpartum nursing.
Methods
This is an applied technological development research.
The Seven Axis Model of ICNP® (7) version 1.0
was used to represent the structural aspects of the
nursing process for data collection, establishment of
diagnoses, nursing interventions and outcomes.
A model based on object guiding was used to
plan the software, which includes: a) Understanding and definition of the context and methods of
using the system; b) System design project; c) Identification of the main objects of the system; d) Development of models and project; e) Specification
of the objects’ interfaces.(8)
The programming language PHP (hypertext
preprocessor) was used to dynamically create the
contents on the web (worldwide web). This type of
language was chosen because it is a programming
language guided by objects, it is portable (it does
not depend on operational systems) and safe, which
allows the running of programs via network with
performance restriction and also presents features
for internationalization, thus natively supporting
unicode characters.
For the development of the database system,
the language SQL (Structure Query Language)
was applied. MySQL (http://www.mysql.com/),
version 5.0.51 was used as the database management system. This choice was due to the fact that
it has a free language, is easy to handle, supports
any platform and does not require many hardware
resources. The platform used was Linux Red Hat
AS 5 and PHP 5.3.
In order to support the development of the system prototype, the researchers chose to work with
usage cases, given that this would facilitate and
guide the programming and review stage.
The system requirements consisted of features
that would permit: (a) the use of ICNP® as a registered support code for the performance of the nurs-
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Acta Paul Enferm. 2013; 26(2):108-15.
ing process; (b) the search for patients through their
personal details; (c) the entry of patients using the
function “admit”, using the form of identification
data or additional information; (d) data entry concerning the first stage of the nursing process (data
collection) in the format of physical examination
data, interview data or additional data; (e) the inclusion of the data collected through menus rather
than in writing; (f ) the free entry of text into the
data collection module; (g) the automatic completion of sentences as the user types, based on the last
sentences written with the same opening words; (h)
the use of data as a form of printed records, which
allowed for the addition of further functions; (i) the
appearance of the ICNP® axes in order of use, which
made user access easier; (j) the possibility (with no
obligation) to automatically create text about patients’ progress based on the collection of data previously entered by users; (l) the creation of reports
by the administrator about the usage practice of
nursing processes, based on statistical data.
The development of the study complied with
national and international guidelines for ethics in
research involving human beings.
Results
The cases of system usage are directly related to
the requirements previously defined, resulting in
actions that are available to users (nurse users and
administrators). Among the actions available to the
nurse users are: login, change password, create reports and exit the system. It also contains functions
related to three other types of functions, such as admission management, patient management and the
nursing process. The actions related to user management and bed management functions are available
to the administrators (Figure 1).
Among its functions, it also provides the possibility of communication among users through
an area of notes the administrator can register for
access by all users and dissemination of important
information about a specific patient, about the system itself or about the institution, thus permitting
communication among users.
Login
Create Reports
Exit System
Change Password
Patient Management
Nursing Process
Register Patients
Register Anamnesis
Seek Patients
Register Physical Examination
View personal data
Register Progress
List Admitted Patients
Register Diagnoses/
Interventions
Common user
(i.e. nurse)
Admission Management
Register Admissions
Seek Progress
View nursing processes
Print Progress
Seek Admissions
Finalize Admissions (Hospital release)
Administrator
Register Initial History
View Initial History
Bed Management
User Management
Register Beds
Register Users
Seek Beds
Seek Users
Figure 1. System usage case diagram
The system functions are presented to users on
the main screen, through a menu on the top of the
page with eight options, as follows: registered patients, admitted patients, beds, users, nursing process, reports, change password and exit.
It is possible to have access to nursing processes, which are sorted in descending order of admission, from the most recent admissions to the first.
This helps to consult the nursing actions that were
performed at other times and the actions that are
being performed referent to the current hospitalization. These registrations of nursing processes
can be done daily or as often as needed. Given that
the nursing activities occur in accordance with dynamics based on established needs and that these
are renewed every time there is a change in health
conditions, the system foresees the need for an indefinite number of processes to be performed per
patient and per day.
The first stage of the nursing process, known as
data collection or nursing history, is subdivided into
two stages: the anamnesis and the physical examination. The anamnesis, which is generally filled out
daily, is composed of the following items: general
health, pain, sleep, nutrition, urinary elimination,
bowel movements, nausea, vomiting, breast, abdomen, suture/surgical incision, bleeding, breastfeeding, movements and care for the newborn.
Concerning the physical examination, the
screen displays a menu with eight items for completion, which cover the basic physical examination of
postpartum women. Users are not required to complete any of the items and can move from one item
to another as they wish. The menu items are: general observations, weight/height, vital signs, head and
neck, chest, abdomen, perineum and extremities.
At the end of the completion of the instrument,
there is an option to save the information registered
into the physical examination database concerning
each of the menus chosen.
Most of the subsequent items in the menu options present pre-established alternatives in order to
minimize the needs of users to write the information. This prevents the occurrence of registration errors, and also speeds up the process of documenting
these data.
The record of the physical examination, similarly to the anamnesis, is unique for each process
and can occur several times a day, depending on the
postpartum women’s needs. This is expected to ocActa Paul Enferm. 2013; 26(2):108-15.
111
cur at least once a day, although it is not mandatory
within the system. The first forms are: general observations, anthropometric measurements and vital
signs. The next forms follow the cerebrospinal flow
of the traditional physical examination; however,
emphasis is given to the assessment of postpartum
women during the immediate and mediate postpartum period.
Nursing diagnoses are developed based on the
seven axis model of ICNP® version 1.0, which requires the mandatory inclusion of at least two axes:
focus and judgment; the others are complementary
and not mandatory.
The system offers all the words found in the
ICNP® for the construction of sentences by simply
entering three letters. Users will see all the words
registered in the ICNP® in that axis, which starts
with that combination of letters, and they can
then choose the word they wish. Then, the referenced ICNP® code associated with each registered
word appears.
The system displays the options of axes in the
order they are usually used in nursing practice. Even
if users decide, for example, that the patient axis
should come before the focus axis, the sequence is
maintained and users have the option to edit the
order of the words in the final sentence, which consequently changes the order of the axes in the sentence (Figure 2).
Figure 2. Nursing Diagnosis Screen in use
In case users are in doubt about the meaning of
that word within the classification, they can identify it by using the function/key DESCRIPTION.
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Acta Paul Enferm. 2013; 26(2):108-15.
The system will open the accurate description and
code found in the classification. Once a word from
the first axis has been chosen, users will continue
making these choices in relation to each remaining
axis, until the desired nursing diagnosis is completed (Figure 3).
Figure 3. Nursing Diagnosis Screen with descriptions of the
axes
Once the nursing diagnosis is completed, the
system permits its editing. It is possible to insert articles, prepositions and others, as well as to change
the gender to female, given that the data registered
relate to postpartum women. This permits better
adjustment and use of the ICNP®, since it is similar to spoken language in daily professional nursing
practice without changing the classification. After
defining the diagnosis, it is possible to save the sentence. For each defined diagnosis, it is possible to
create possibilities of nursing prescriptions specifically for that defined diagnosis.
The planning, similarly to what occurs with the
nursing diagnosis, is developed with the help of the
seven axis model. However, there are no mandatory
axes and only the axis judgment cannot be used.
Normally, the action and method axes are used,
while the other axes are complementary. As with the
nursing diagnosis, the system shows all the words
prior to the terms for the composition, besides the
function DESCRIPTION (Figure 4).
Once the nursing prescription has been completed, the system enables its edition. It is possible
to insert articles, prepositions, as well as to change
the gender, like with the nursing diagnoses. After
defining the nursing prescription, the sentence
Figure 4. Formulation of Nursing Prescriptions Screen
needs to be saved. This generates a list of prescriptions for the previously defined diagnosis.
It is possible for users to exclude a previously
created prescription at any time before saving the
list of nursing prescriptions. However, once that
prescription is saved, it can only be suspended with
a new prescription, within a new nursing process
(Figure 5).
Figure 5. Nursing Prescriptions Screen with list
The nursing progress, an important form of
nursing records, is made within the system through
previous data automatically entered during data collection, either about the physical examination or on
the anamnesis. At the end of each list of prescribed
interventions, it is possible to generate it as a printed
document and move to the automatic execution of
nursing progress, based on the data collected during
the physical examination and anamnesis.
By choosing the icon GENERATE PROGRESS, the users will be provided with a pre-defined
automatic text that follows the guide, the sequence
and information of data collection. However, similarly to what occurs with the nursing diagnoses
and prescriptions through a list of interventions, it
is possible to edit the entire progress text, changing the places of sentences, improving verbal and
nominal conformity, adjusting gender and number,
excluding or including information, among others.
This preserves professional autonomy and ensures
that the nurses provide the final authorization for
the progress text.
The function REPORTS can be viewed in the
main menu. This function permits generating, using the data collected and stored, important information for clinical decision-making and change the
conduct previously defined. At first, this function is
limited to the frequency of each of the variables contained in the database and the correlation between
these variables. For example: if there is the need to
evaluate the effectiveness of a particular treatment
prescribed by nurses for a particular nursing diagnosis, the relationship between the variables “adopted interventions” and “achieved outcome” can be
evaluated, based on a given nursing diagnosis, by
maintaining some variables fixed in order to ensure
that the sample the system is working on has the
same features and avoid selection bias.
Through the frequent use of the system and
when a certain number of significant nursing processes is achieved, by way of reports and statistical
evaluations, it is possible to conclude that a particular conduct is valid. Therefore, through the function
REPORTS, it will be possible to invest in further
research, aimed at making clinical decisions based
on scientific evidence.
Discussion
The prototype presented herein is aimed at improving the quality of care and the performance of nurses in relation to the nursing process. It was evident
that some aspects should be considered when developing a database system, which are: understanding
the difference between content and format (or data
and presentation); standardizing content and clinical data, given the diversity of methods used for
presentation; establishing the content in conjunction with the workflow process through the system;
Acta Paul Enferm. 2013; 26(2):108-15.
113
collecting and registering data; undertaking recovery and review of data and information; dealing
with communication in between and during shifts
and among departments.(9)
The distinguished importance of the content
used, following the classical course of the nursing
process, and the way in which this content was presented resulted in a clear and objective system. The
use of a standardized language through the International Classification for Nursing Practice - ICNP®
guarantees the standardization of clinical data.
The judicious application of a nursing classification results in more accurate nursing diagnoses.
Nurses are then able to choose more effective nursing interventions, which significantly add up to patients’ outcomes.(10)
Furthermore, the sequence that is didactically
used was followed, which facilitated the maintenance of nurses’ daily practice and avoided that
the system would affect these professionals’ work
process.
The existence of a function that ensures communication among nurses with regard to the nursing process used related to each postpartum woman
or problems, or yet any particularity of patient care
or any institutional information represents a distinguishing feature of the system, since it guarantees
the emphasis on passing information from one shift
to another, which can also be set as a priority.
An automated database system improves management, healthcare delivery and reimbursement,
since it limits data entry errors and reduces costs.(11)
This system, besides ensuring that data are recorded, is also able to retrieve information about
previously performed nursing processes, so as to
serve as a parameter for other records of nursing
processes. This allows that nurses to adequately
evaluate the patients’ progress.
In nursing, there are three large areas related to
healthcare information systems that need to be addressed in the immediate future in order to assist
the nurses with information management. These
are: collection of data in the source, nursing data
standards and decision-making support systems.(9)
The proposed system immediately ensures the
use of standards for nursing data, since it propos-
114
Acta Paul Enferm. 2013; 26(2):108-15.
es the use of a standardized language. But it does
not have a standardized system of data collection
at the hospital beds, nor is a system to support
decision-making. However, the selection of a programming language that can be used in networks
has presented, since the beginning of the prototype
process, the possibility for further adjustment of the
system to work from mobile devices and being close
to patients. In addition, after some time of use and
through reports, the system will serve as a research
resource to evaluate the effectiveness of nursing interventions concerning postpartum women and enable further adjustment to a module of the support
system for clinical decision-making about postpartum nursing care.
The use of ICNP® in this system can promote
the development and use of a multitude of diagnoses, intervention and nursing outcomes in relation
to postpartum women and further assist to overcome the difficulties midwives face in the performance of the nursing process.
The classification used (ICNP® 1.0) proved to
be a terminology that promotes organization, control and logical view of the clinical reasoning in
the patient care process with the use of automated
resources, because it allows nurses to establish a
solid relationship between nursing diagnoses and
interventions.(12)
Conclusion
The prototype of the puerperal nursing documentation system was successfully developed, permitting
nursing records using standardized language.
Acknowledgements
Dr. Marin received partial funding from
NIH D43TW007015, BRIGHT and CNPq
301735/2009.
Collaborations
Veríssimo RCSS and Marin HF declare that they
substantially contributed to the conception and development of the research, writing, revision of the paper and final approval of the version for publication.
References
1. Hannah KJ, Ball MJ, Edwards MJA. Introdução à Informática em
Enfermagem. 3a ed. Porto Alegre: Artmed, 2009.
2. Marin HF, Rodrigues RJ, Delaney C, Nielsen GH, Yan J, editors. Desarrollo
de Sistemas Normalizados de Información de Enfermería. Organización
Panamericana de la Salud, Washington (DC); 2001. 160 p.
3. Santos SR, Nóbrega MM. A busca da integração teoria e prática
no sistema de informação em enfermagem. Enfoque na teoria
fundamentada nos dados. Rev Latinoam Enferm. 2004;12(3):460-8.
4. Marin HF. Azevedo CM. Avaliação da informação registrada em
prontuários de pacientes internados em uma enfermaria obstétrica.
Acta Paul Enferm. 2003;16(1):7-13.
5. International classification of nursing practice (ICNP). Disponível em:
http://www.icn.ch/pillarsprograms/international-classification-fornursing-practice-icnpr/
6. Reis EA. Marin HF. Necessidades e expectativas dos enfermeiros em
relação aos sistemas informatizados [Internet]. [citado 2013 Abr 2].
Disponível em: http://www.sbis.org.br/cbis9/arquivos/273.doc
7. Freitas MC, Queiroz TA, Souza JA. O processo de enfermagem sob
a ótica das enfermeiras de uma maternidade. Rev Bras Enferm.
2007;60(2):207-12.
8. Sommerville I. Engenharia de software. 6a ed. São Paulo: Pearson
Addison Wesley; 2003.
9. Hannah KJ, Ball MJ, Edwards MJ. Aspectos de Enfermagem nos
Sistemas de Informação em Saúde. In: Hannah KJ, Ball MJ, Edwards
MJA. Introdução à Informática em Enfermagem. 3ª ed. Porto Alegre:
Artmed; 2009. p.101-19.
10.Müller-Staub M. Studies about use and application of nursing
classifications. Pflege Z. 2009;62(6):354-9.
11. Menke JA, Broner CW, Campbell DY, McKissick MY, Edwards-Beckett
JA. Computerized clinical documentation system in the pediatric
intensive care unit. BMC Med Inform Decis Making. 2001;1(1):3.
12.Antunes CR, Dal Sasso GT. Processo de enfermagem informatizado
ao paciente politraumatizado de terapia intensiva via web [Internet].
[citado 2013 Abr 2]. Disponível em: http://www.sbis.org.br/cbis/
arquivos/1039.pdf.
Acta Paul Enferm. 2013; 26(2):108-15.
115
Original Article
Nursing workload in the postanesthesia care unit
Carga de trabalho de enfermagem em unidade
de recuperação pós-anestésica
Luciana Bjorklund de Lima1
Eneida Rejane Rabelo1
Keywords
Nursing staff; Nursing care;
Perioperative nursing; Workload;
Severity of illness index
Descritores
Recursos humanos de enfermagem;
Cuidados de enfermagem; Enfermagem
perioperatória; Carga de trabalho;
Índice de gravidade de doença
Submitted
October 17, 2011
Accepted
February 21, 2013
Eneida Rejane Rabelo
São Manoel street, 963, Porto Alegre,
RS, Brazil. Zip Code: 90620-110
[email protected]
116
Acta Paul Enferm. 2013; 26(2):116-22.
Abstract
Objectives: To assess nursing workload in the post-anesthesia care unit and its potential correlations with a
surgical severity index, length of stay, magnitude of surgery, and patient age.
Methods: Cross-sectional study conducted at a university hospital. Workload was assessed by the Nursing
Activities Score, and severity of illness, by the Simplified Acute Physiology Score II. Both were assessed at the
time of discharge from the unit.
Results: The study sample comprised 160 patients (mean age, 57 ± 15 years). The median nursing workload
was 45.6 minutes per hour, i.e. 50% of patients required 45.6 minutes of nursing care per hour spent in the
post-anesthesia care unit. There was no association between workload and severity index. However, there
were positive correlations among workload, length of stay, and magnitude of surgery. The severity of illness
was correlated with age.
Conclusion: Nursing workload in the post-anesthesia care unit is influenced by length of stay and magnitude
of surgery.
Resumo
Objetivos: Avaliar a carga de trabalho de enfermagem em unidade de recuperação pós-anestésica e relacionar
com o índice de gravidade cirúrgico, tempo de permanência, porte cirúrgico e idade.
Métodos: Estudo transversal conduzido em hospital universitário. A carga de trabalho foi avaliada pelo
Nursing Activities Score e o índice de gravidade pelo Simplified Acute Physiology Score II aplicados na alta da
unidade de recuperação.
Resultados: Foram incluídos 160 pacientes, idade média 57±15 anos. A carga de trabalho para 50% dos
pacientes foi de 45,6 minutos a cada hora de permanência na unidade. Não houve relação entre carga de
trabalho e índice de gravidade. Contudo, houve correlações positivas entre carga de trabalho, tempo de
permanência e porte cirúrgico. O índice de gravidade apresentou correlação com a idade.
Conclusão: A carga de trabalho de enfermagem em unidade de recuperação pós-anestésica sofre influência
do tempo de permanência e do porte cirúrgico.
Escola de Enfermagem, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
Conflicts of interest: the authors have no conflicts of interest to declare.
1
Lima LB, Rabelo ER
Introduction
The purpose of the post-anesthesia care unit is
to provide immediate postoperative care to patients who have received general and/or regional
anesthesia. During this time, nursing care focuses on monitoring the return of consciousness,
the recovery of airway protective reflexes and
the stability of vital signs. The post-anesthesia
care unit has a series of unique characteristics
and routines, and often hosts patients requiring
high-complexity care.(1)
The profile of patients admitted to the
post-anesthesia care unit determines the degree
of surveillance required to prevent or mitigate
complications. In a study designed to identify
the most prevalent complications at a post-anesthesia care unit and their potential correlations
with nursing interventions and the presence of
nurses in the unit, pain and hypothermia were
found to be among the most common complications. The nursing interventions correlated with
pain were routine care (cardiac rhythm and vital
signs monitoring, safety surveillance, monitoring
and assessment of physical and emotional state),
oxygen therapy, medication administration, and
wound care. Presence of a nurse at the unit was
associated with immediate detection of pain,
nausea, vomiting, agitation, anxiety, and bleeding. The results of this study highlight the importance of the nursing team in the prevention and
management of postoperative complications and
provides insight into the nursing activities carried out in the post-anesthesia recovery setting.(1)
Surgical complications may be associated with
clinical variables, the complexity of surgery, or operative time;(1-3) these aspects may, in turn, lead to
an increase in nursing workload. Studies confirm
that the nursing workload in the post-anesthesia
care unit is greater when more severely ill patients
are present and when the number of adverse events
is higher.(2,3)
Although the postoperative needs of surgical
patients are well known, there has been little research into the time spent on provision of postoperative care. In the Brazilian context, knowledge
of the adequacy of nursing workload as a function
of patient needs in the post-anesthesia care unit is
still incipient. A greater knowledge of this topic
by nurses can play a relevant role in care planning,
nurse staffing, and use of technological resources
so as to ensure delivery of safe, proactive postoperative care. From this perspective, the present study
sought to assess nursing workload at a post-anesthesia care unit and its potential correlations with
a surgical severity index, length of stay, magnitude
of surgery, and patient age.
Methods
This was a cross-sectional study conducted at the
post-anesthesia care unit of a public teaching hospital in Porto Alegre, state of Rio Grande do Sul,
Brazil, between July 2008 and September 2009.
Sample size was calculated for a significance level of 0.05, a statistical power of 95%, and an alpha
of 5%. These parameters were based on previous
studies of the Nursing Activities Score (NAS) in an
intensive care unit setting,(4-6) and yielded a sample
size of 160 patients.
The sample comprised adult patients (age ≥18
years) who had undergone elective surgical procedures requiring anesthesia. Patients who underwent outpatient surgery, required local anesthesia
and/or sedation alone, or had a length of post-anesthesia care unit stay ≤1 hour were excluded. Patients were recruited by simple random sampling
of the hospital’s surgical schedule. Patients were
selected from the schedule by age and procedure
and assessed for the inclusion and exclusion criteria. After this screening stage, patients were randomly selected by chart number (or initials when
the chart number was absent). Data collection
was carried out every other day, Monday through
Friday, throughout the study period.
The instrument used for assessment of nursing workload per patient was the NAS,(7) in its
validated Brazilian Portuguese version.(6) The
NAS instrument covers a set of 23 activities with
predefined scores, and the final score represents
the percentage of time spent on nursing care of
Acta Paul Enferm. 2013; 26(2):116-22.
117
a particular patient over a 24-hour period. Each
point corresponds to 14.4 minutes of nursing
care, and the total NAS score may range from 0%
to 100% or more. A score of 100% means that
the patient requires the exclusive attention of one
nurse per shift.(5,7) For use of the NAS instrument at the study unit, we developed a tutorial
for scoring of the nursing activities carried out in
a post-anesthesia care unit setting.(5,8,9)
The Simplified Acute Physiology Score II
(SAPS II) was used for assessment of surgical severity. The SAPS II uses 34 physiological variables
(not considering primary diagnosis) to assess the
risk of in-hospital mortality, and has been widely
used in clinical research to assess risk of death in
intensive care unit patients.(9)
Data was collected on patient age, sex, American Society of Anesthesiologists (ASA) class,
type of anesthesia, surgical service, magnitude of
surgery, length of post-anesthesia care unit stay,
and patient disposition after post-anesthesia care
unit discharge.
Clinical and demographic data were collected
by the lead investigator and by a trained nurse
intern. The nursing workload and severity instruments were administered by the lead investigator.
The first stage of data collection was sample
identification and characterization. Information
on ASA class was obtained from anesthesia records completed by the anesthesiologist. Data for
nursing workload and severity index calculation
were obtained at the time of patient discharge
from the study unit. Data were obtained by a review of laboratory test results in electronic medical records, analysis of nursing notes completed
in the immediate postoperative period, and direct observation of each patient at the time of
instrument administration.
All analyses were performed in the SPSS® (Statistical Package for the Social Sciences) 17.0 software environments. Categorical variables were
expressed as absolute or relative frequencies, and
continuous variables, as mean ± standard deviation or median and interquartile range as appropriate. Pearson’s correlation coefficient was used
to test for correlation between NAS scores and
118
Acta Paul Enferm. 2013; 26(2):116-22.
SAPS II severity index, patient age, magnitude of
surgery, and length of post-anesthesia care unit
stay. P-values < 0.05 were considered significant.
All study procedures were carried out in accordance with Brazilian and international ethical standards for human subjects research.
Results
The study sample comprised 160 patients, with
a mean age of 57±15 years, 81 (50.6%) of whom
were female and 79 (49.4%) male; 103 (64.4%)
were classified as ASA class 2. The most common
type of anesthesia was general (n=97, 60.6%). The
most prevalent surgical services were urology, general surgery, digestive system surgery, and thoracic
surgery, in this order. The mean SAPS II score was
14.3±7.7, and the most common magnitude of
surgery was class 2. The median length of PACU
stay was 4.83 (3.43 – 6.72) hours, and 99.4%
of patients were discharged to inpatient units or
wards. These results are summarized in table 1.
The nursing workload per patient was calculated proportionally according to length of stay at
the post-anesthesia care unit. The median nursing workload per patient was 76.2 (interquartile
range, 70.47 – 84.6) points, corresponding to a
median 3.68 hours of nursing care to meet the
needs of up to 50% of the sample. There was
no correlation between workload per patient and
severity index.
Table 2 shows correlations between the variables of interest – age, length of post-anesthesia
care unit stay, magnitude of surgery – and nursing workload and severity score. Nursing workload was strongly correlated with length of stay,
whereas disease severity was strongly correlated
with age. Magnitude of surgery was moderately
correlated with nursing workload.
Discussion
The present study was designed to assess nursing
workload in a post-anesthesia care unit and its po
Lima LB, Rabelo ER
Tabela 1. Características clínicas e demográficas
Characteristics
n(%)
Sex
Female
81(50.6)
Male
79(49.4)
American Society of Anesthesiologists (ASA) class†(n%)†
ASA 1
20(12.5)
ASA 2
103(64.4)
ASA 3
36(22.5)
Not classified
1(0.6)
Type of anesthesia
General
97(60.6)
Regional (epidural and/or subarachnoid blockade)
26(16.3)
General + regional (epidural and/or subarachnoid
blockade)
37(23.1)
Surgical service
Urology
26(16.2)
General surgery
23(14.4)
Digestive system surgery
21(13.1)
Thoracic surgery
16(10)
Orthopedic surgery
14(8.8)
Ear/nose/throat
14(8.8)
Obstetrics/gynecolog
13(8.0)
Colorectal surgery
11(6.9)
Breast surgery
8(5)
Vascular surgery
7(4.4)
Neurosurgery
4(2.5)
Plastic surgery
3(1.9)
Magnitude of surgery
1
33(20.6)
2
85(53.1)
3
35(21.9)
4
7(4.4)
Patient disposition after PACU discharge
Inpatient unit/ward
159(99.4)
Intensive care unit
1(0.6)
Legend: n=160; Age (years) 57±15; Mean ± standard deviation; †No patients
were classified as ASA 4, 5 and 6; ‡Median (interquartile range); Simplified
Acute Physiology Score II (SAPS II) 14.3±7.7; Severity index SAPS II‡1.7%
(0.6% – 3.7%); Length of stay at PACU (hours)‡ 4.83(3.43 – 6.72)
Tabela 2. Correlação entre variáveis do estudo e instrumentos
selecionados
NAS
Variable
SAPS severity
index II
R*
p-value
R*
p-value
Age
0.133
0.094
0.508
<0.001
Length of stay
0.797
<0.001
0.165
0.037
Magnitude of surgery
0.419
<0.001
-0.019
0.814
Legend: Pearson’s correlation coefficient
tential correlations with severity score, length of
stay, magnitude of surgery, and age.
The severity scores found herein were lower
than those reported elsewhere. A study of nursing workload and severity in patients status post
cardiac surgery reported SAPS II scores of 26±11
points, with a severity index of 10.65%.(5) In the
post-anesthesia care unit of a Greek hospital, the
mean severity index as measured by the SAPS II
was 29.7%±18.8.(2) In both studies, there was a
statistically significant association between severity
and nursing workload.(2,5)
In the present study, there was no correlation
between nursing workload as measured by the NAS
and SAPS II severity index. These findings are consistent with the collected data, in that most patients
remained clinically stable and were transferred to
inpatient units. We infer that these results reflect
the specificity of the post-anesthesia recovery room
as a unit for the transition period between awakening from anesthesia and recovery of normal vital parameters, with a view to transfer to admission units/
wards or hospital discharge.
Although nearly 100% of patients were discharged to inpatient units, the mean length of
post-anesthesia care unit stay was quite prolonged.
The need for clinical management of postoperative
adverse events (such as nausea, vomiting, pain) and
situations such as waiting for reassessment by the
surgical team prior to post-anesthesia care unit discharge may have contributed to these findings. All
adverse event management activities have an impact
on nursing workload, as nursing interventions must
be reassessed for effectiveness.(1,10)
In the present study, there was no significant
correlation between workload and patient age. SimActa Paul Enferm. 2013; 26(2):116-22.
119
ilar findings have been reported by other investigators.(11,12) Conversely, there was a strong correlation
between age and severity score. A study conducted
at the intensive care unit of a nonprofit hospital
in the state of Paraná assessed patient severity by
means of the APACHE II score .The results showed
that patients over the age of 60 years were more
likely to have comorbidities.(13)
A study conducted at the intensive care unit of a
university hospital in São Paulo assessed differences
in nursing workload (NAS) and severity (SAPS II)
among elderly and non-elderly patients. The authors found that nursing workload was no different
among elderly patients of different age ranges, but
patients aged 80 or older had the highest severity
indices (66.7%). One may conclude that these patients exhibited more severe clinical instability, as
most were admitted to the ICU for management of
respiratory conditions.(14)
Furthermore, the need for intensive or high-dependency care to restore patient stability entails a
greater number of nursing interventions(1) and, consequently, a heavier workload. It bears stressing that,
in the immediate postoperative period, older adults
require closer surveillance of vital signs (particularly
respiratory parameters), more intensive pain management, and are more dependent on the nursing
staff for positioning and emotional support.
The present investigation revealed a strong
correlation between requiring longer nursing
care hours and length of post-anesthesia care unit
stay. The results of a study that assessed the daily
progression of nursing workload in the intensive
care unit of a teaching hospital in São Paulo with
the NAS instrument showed that patients with
longer unit stays are more demanding in terms of
nursing workload.(11)
A previous Brazilian study assessed the level of
dependence on nursing care and its association with
patient severity in the post-anesthesia care unit of
a general university hospital. The results showed a
high prevalence of patients classified as requiring
intermediate or high-dependency care. The median
length of stay was 4.08 (3.00 – 4.91) hours for minimally dependent patients, 4.26 (3.19 – 6.00) for
patients requiring intermediate care, 5.50 (4.10 –
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Acta Paul Enferm. 2013; 26(2):116-22.
12.58) hours for patients requiring high-dependency care, and 16.91 (8.58 – 18.79) hours for those
requiring intensive care.(15)
These results corroborate the findings of the
present study, showing that, even after the critical
first hour after surgery has passed, patients still require surveillance and other nursing interventions.
(1)
Once airway protective reflexes and consciousness
have returned, patients require verbal management
to establish a therapeutic relationship with their care
providers. The purpose of verbal contact in this setting is to provide emotional support. Patients also
require pharmacological and non-pharmacological
management of acute pain, care of bodily functions
(feeding and excretion), and mobilization in accordance with postoperative restrictions.
The moderate correlation between magnitude of surgery and nursing workload identified
in this study suggests that patients who undergo
prolonged surgical procedures and prolonged anesthesia require more time-intensive nursing care
in the postoperative period. In this study, magnitude of surgery was classified according to the
duration of operating room use.(16) Class 1, 0–2h;
class 2, 2h01min–4h; class 3, 4h01min–6h; and
class 4, >6h01min.(16)
A study conducted at a United States hospital assessed dependent factors for post-anesthesia
care unit length of stay, with a focus on operative
time and duration of anesthesia. Of 340 patients
assessed, 35% had an operative time of >2 hours,
and 38% had a duration of anesthesia of >3 hours.
Duration of anesthesia correlated significantly with
delays in patient discharge from the post-anesthesia care unit, and, consequently, had an impact on
length of unit stay and nursing workload.(17)
Prolonged anesthesia and operative time predispose patients to hypothermia, pain and cutaneous lesions associated with surgical positioning
and increase the risk of hemodynamic and respiratory instability due to exposure to higher doses
of anesthetic agents.(1) On detection of these instabilities, nursing staff must immediately attempt to
minimize complications. One highly time-intensive intervention is inspection of the patient’s skin
for areas of hyperemia, burns, or loss of cutaneous
Lima LB, Rabelo ER
sensation that may be associated with surgical or
anesthetic complications. Furthermore, these patients require strict monitoring and surveillance
of vital signs, as events such as hypothermia and
pain trigger major physiological changes, with the
potential for hypoventilation and heart failure.(1,18)
Furthermore, recording of vital signs and nursing notes requires discipline and responsibility, as
these records enable monitoring of patient progress in the postoperative period.
Data on workload will enable planning of
nurse staffing levels for this specialized setting. The
post-anesthesia care unit has a number of specificities as compared with other hospital units.
Post-anesthesia care unit processes and procedures
are distinguished – particularly as compared with
those of the intensive care unit – by the high patient
turnover of post-anesthesia care and by the need for
extremely agile decision-making to address postoperative complications.(1,18)
In the present study, workload was calculated
proportionally in relation to length of post-anesthesia care unit stay. This calculation may differ
from mean NAS score over a 24-hour period, but
the findings obtained are nevertheless indicative of
a substantial nursing workload.
In spite of the differences between intensive care
and post-anesthesia care, the present study showed,
that, with each hour in the unit, 50% of patients
will require 45.6 minutes of nursing care. For a
length of stay of 3 to 6 hours, 2.28 to 4.56 hours
of nursing care will be expended on a single patient
respectively; this information is highly relevant to
planning and management of nursing care in the
post-anesthesia setting. These results, taken together with other useful data – such as degree of
patient dependence, safe staffing requirements, and
productive time – enable quantitative calculation of
optimal nurse staffing levels for the post-anesthesia
care unit.
From the results of this study, we infer that nursing workload per patient in the post-anesthesia care
unit setting is influenced by length of stay and magnitude of surgery. Knowledge of these factors by nursing
teams may help apportion human and technological
resources for better care of postoperative patients.
Conclusion
The median nursing workload (for 50% of patients)
at the post-anesthesia care unit where this study was
conducted was 45.6 minutes per hour of unit stay.
Nursing workload did not correlate with surgical severity index. However, there was a strong correlation between nursing workload and length of
stay at the post-anesthesia care unit, and a moderate
correlation between nursing workload and magnitude of surgery. Severity scores correlated moderately with age.
In short, nursing workload in the post-anesthesia care unit setting is influenced by length of stay
and magnitude of surgery.
Acknowledgements
Financial support for this study was provided by
Fundo de Incentivo à Pesquisa e Eventos (FIPE) do
Hospital de Clínicas de Porto Alegre, RS, Brazil.
Collaborations
Lima LB and Rabelo ER contributed equally to
study conception and design, data analysis and interpretation, manuscript preparation, and critical
revision of the manuscript for important intellectual content. Both authors gave final approval of the
version to be published.
References
1. Popov DC, Peniche AC. Nurse interventions and the complications
in the post-anesthesia recovery room. Rev Esc Enferm USP.
2009;43(4):946-54.
2. Kiekkas P, Poulopoulou M, Papahatzi A, Androutsopoulou C, Maliouki M,
Prinou A. Workload of postanaesthesia care unit nurses and intensive
care overflow. Br J Nurs. 2005;14(8):434-8.
3. Cohen MM, O’Brien-Pallas LL, Copplestone C, Wall R, Porter J,
Rose DK. Nursing workload associated with adverse events in the
postanesthesia care unit. Anesthesiology. 1999;91(6):1882-90.
4. Conishi RM, Gaidzinski RR. Evaluation of the Nursing Activities Score
(NAS) as a nursing workload measurement tool in an adult ICU. Rev Esc
Enferm USP. 2007;41(3):346-54.
5. Dias MC. Aplicação do Nursing Activities Score – N. A. S. – como
instrumento de medida de carga de trabalho em enfermagem em
UTI cirúrgica cardiológica [dissertação]. São Paulo: Universidade
de São Paulo, Escola de Enfermagem; 2006 [citado 2013 Feb 20].
Disponível em: http://www.teses.usp.br/teses/disponiveis/7/7131/
tde-17102006-131800/pt-br.php>.
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6. Queijo AF, Padilha KG. Nursing Activities Score (NAS): cross-cultural
adaptation and validation to portuguese language. Rev Esc Enferm
USP. 2009;43(Esp):1018-25.
7. Miranda DR, Nap R, de Rijk A, Schaufeli W, Iapichino G; TISS Working
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score. Crit Care Med. 2003;31(2):374-82.
8.Nursing Activities Scores: instructions for use. Crit Care
Med [Internet] [cited 2009 Dec 28]. Available from: http://
download.lww.com/wolterskluwer_vitalstream_com/PermaLink/
CCM/A/00003246-920030200-00001.pdf
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(NAS) em neonatologia [tese]. São Paulo: Universidade de São Paulo,
Escola de Enfermagem; 2007. [citado 2013 Mar 5]. Disponível em:
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10.Kiekkas P, Poulopoulou M, Papahatzi A, Androutsopoulou C, Maliouki
M, Prinou A. Nursing activities and use of time in the postanesthesia
care unit. J Perianesth Nurs. 2005;20(5):311-22.
11.Gonçalves LA, Garcia PC, Toffoleto MC, Telles SC, Padilha KG.The
need for nursing care in Intensive Care Units: daily patient assessment
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12. Gonçalves LA, Padilha KG.Factors associated with nursing workload in
adult intensive care units. Rev Esc Enferm USP. 2007;41(4):645-52.
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prospective application of the APACHE II index. Rev Latinoam Enferm.
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14. Sousa CR, Gonçalves LA, Toffoleto MC, Leão K, Padilha KG. Predictors
of nursing workload in elderly patients admitted to intensive care units.
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2007;20(2):151-60.
Original Article
Concurrent Validation of Nursing Scores (the
NEMS and TISS-28) in pediatric intensive care
Validação Concorrente de Escores de Enfermagem
(NEMS e TISS-28) em terapia intensiva pediátrica
Simone Travi Canabarro1
Kelly Dayane Stochero Velozo2
Olga Rosária Eidt2
Jefferson Pedro Piva2
Pedro Celiny Ramos Garcia2
Keywords
Intensive care units; Nursing; Pediatric
nursing; Indicators; Practical nursing
Descritores
Unidades de terapia intensiva;
Enfermagem; Enfermagem pediátrica;
Indicadores; Enfermagem prática
Submitted
December 26, 2011
Accepted
March 27, 2013
Abstract
Objective: Examine the concurrent validity of the Nine Equivalents of Nursing Manpower Use Score (NEMS)
in comparison to the Therapeutic Intervention Scoring System-28 (TISS-28) in a Pediatric Intensive Care Unit
(PICU).
Methods: Prospective observational cohort study conducted in a PICU of a Brazilian university hospital over
a period of two years with a sample of 816 patients. A total of 7,702 observations were obtained for each of
the scores.
Results: The average maximum score of the NEMS was 26.6±9.2 and for the TISS-28 it was 21.3±8.2. The
TISS-28 was lower than the NEMS (p<0.001) for all the averages. A good correlation was observed between
them (r2=0.704) for all observations. Agreement between the TISS-28 and the NEMS was good, presenting
only a 6.2% difference between the scores.
Conclusion: The results show good correlation and agreement between the TISS-28 and the NEMS, enabling
the NEMS validation in this population of pediatric patients.
Resumo
Objetivo: Examinar a validade concorrente do escore Nine Equivalents of Nursing Manpower Use Score
(NEMS) em comparação ao Therapeutic Intervention Scoring System-28 (TISS-28) em uma Unidade de
Terapia Intensiva Pediátrica (UTIP).
Métodos: Estudo de coorte prospectivo observacional, realizado na UTIP de um hospital universitário brasileiro,
no período de dois anos, com uma amostra de 816 pacientes. Foram realizadas 7.702 observações de cada
um dos escores.
Resultados: A média da pontuação máxima do NEMS foi 26,6±9,2 e do TISS-28 21,3±8,2. Em todas as
médias, o TISS-28 foi inferior ao NEMS (p<0,001). Houve uma boa correlação entre eles (r2=0,704 para todas
as observações). A concordância entre o TISS-28 e o NEMS foi boa, apresentando apenas 6,2% de diferença
entre os escores.
Conclusão: Os resultados mostraram boa correlação e concordância entre o TISS-28 e o NEMS, permitindo
validar o NEMS nessa população de pacientes pediátricos.
Simone Travi Canabarro
Sarmento Leite street, 245, Porto
Alegre, RS, Brazil. Zip Code: 90050170
[email protected]
Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil.
Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil.
Conflict of interest: no conflicts of interest to declare.
1
2
Acta Paul Enferm. 2013; 26(2):123-9.
123
Concurrent Validation of Nursing Scores (the NEMS and TISS-28) in pediatric intensive care
124
Introduction
Methods
Intensive Care Units (ICUs) are seen as critical
care areas that demand highly specialized professionals, advanced technology and the organization of work processes, which result in increased
concern related to costs and operationalization.
Therefore, they require proper documentation
and a preview of measurable parameters that
qualify and quantify care delivery that is essential
for children hospitalized in Pediatric Intensive
Care Units (PICUs).
Nurses can use tools to identify the severity of
patient conditions, therapeutic interventions and
the requirements of nursing care in intensive therapy. The use of scores enables the assessment of
certain characteristics presented by patients, contributing to decision-making and evidence-based
practice. The Therapeutic Intervention Scoring
System was originally presented in 1974. Some
changes were implemented to it over time and its
simplified version is currently the most disseminated of its versions.(1,2) The Therapeutic Intervention Scoring System-28 (TISS-28), presented in
1996, is composed of 28 items designed to measure the severity of the disease and nursing workload.(2,3) The creation of the Nine Equivalents of
Nursing Use Manpower (NEMS)(2,4) was based on
the TISS-28.
Work processes within the dynamics of ICUs
require optimization of time and feasibility of
implementation; the NEMS is an agile tool because it presents only nine items as variables.(1,5,6)
The NEMS is also appropriate for the management of nursing professionals who work
in intensive therapy and for the evaluation of
ICUs.(7-9)
Studies validating NEMS were implemented
with clinical and surgical patients hospitalized
in adult ICUs,(4,10) however, such studies are rare
and seldom implemented in pediatric units.(5)
The primary objective of this study is to examine
the concurrent validity of the NEMS in comparison to the TISS-28 in a Pediatric Intensive
Therapy Unit.
This is a prospective observational cohort study
conducted in a level III Pediatric Intensive Care
Unit at São Lucas Hospital, Pontifícia Universidade
Católica do Rio Grande do Sul. The study was conducted between October 1st, 2006 and September
30th, 2008. The sample was composed of patients
aged between 28 days and 18 years old who were
hospitalized in the PICU. All the children who remained in the unit for more than eight hours, regardless of the severity of their condition, and for a
period of four hours or longer in the case of death,
were included. Patients who were readmitted to the
PICU after being discharged from other Units were
considered new patients.
Sample size was computed based on an average
population of 400 patients hospitalized in the PICU
per year. A total of 800 pediatric hospitalizations in
the PICU were estimated over a period of two years.
The sample power was computed with a level of significance set at 5% to detect the main associations
of interest. Thus, the sample presents a power of
100% to evaluate the association between a cut off
point of 50% of the categories of the NEMS and
TISS-28, with mortality estimated to be 6%.
Data were collected from the medical charts of
patients hospitalized in the PICU and the instrument was composed of two parts: the first part was
composed of therapeutic interventions from the
TISS-28 and NEMS(4) adapted for follow-up until
discharge or death; the second part addressed socio-demographic data in addition to the Pediatric
Risk of Mortality (PRISM).(11)
The TISS-28’s therapeutic interventions include
seven categories that correspond to: basic activities,
ventilator support, cardiovascular support, renal
support, neurological support, metabolic support,
and specific interventions. Each of these parameters
is composed of items with scores that range from
one to eight, totaling 28 measures.(3) The NEMS
includes nine items: basic monitoring, intravenous
medication, mechanical ventilator support, supplementary ventilatory care, single vasoactive medication, multiple vasoactive medication, hemofiltra-
Acta Paul Enferm. 2013; 26(2):123-9.
Canabarro ST, Velozo KDS, Eidt OR, Piva JP, Garcia PCR
tion and/or dialysis techniques, specific intervention in the ICU, and specific interventions outside
the ICU.(4)
Data were collected daily by four RNs during
the child’s entire hospitalization from 12pm to 2pm
using the records on the patient’s chart concerning
the last 24 hours of hospitalization in the Unit.
The team of nurses collecting data was previously
trained. After this stage, the Kappa test was applied
to verify inter-rater agreement. Agreement at 0.85
was obtained, which indicates strong agreement.
Collected data were reviewed by the nurse researcher and stored in a database in a Microsoft Office
Excel® spreadsheet to be analyzed later using the
Statistical Package for the Social Sciences® (SPSS),
version 17.0.
The results were considered significant when
p≤0.05. Continuous variables with normal distribution were presented in averages (± standard deviation) and categorical variables in percentages.
Continuous variables with non-normal distribution
were expressed in medians and interquartile intervals (CI95%). When indicated, the categorical variables were compared using the Chi-square test or
Fisher’s Exact test, while Student’s t test was used to
compare the averages.
The population’s mortality was reviewed with
the Standard Mortality Ratio (SMR) computation, which is based on the PRISM. It is a reliable indicator of severity that was validated by the
authors(12) and used in the institution during the
study. SMR corresponds to the ratio between observed and expected mortality and its variation,
assessed according to standard deviation, the values of which confirm the hypothesis that observed
mortality is equal to the expected when ±1.96. The
Area Under Curve Receiver Operating Characteristic (AUROC) was used to assess sensitivity (correct prediction of death) and specificity (correct
prediction of survival).
The correlation of results between the two
scores, the NEMS and the TISS-28 (continuous
variables), was tested using Pearson’s linear correlation, analyzing the degree of association between
both, and customization was performed through
binary logistic regression analysis. To interpret the
results of linear correlation,(13) we considered “r” between 0.0–0.3 to be weak, 0.3-0.6 to be moderate
and >0.6 to be strong correlation.
Bland & Altman plotting(14) was used in the
analysis of agreement to verify the variation of
scores. We considered the analysis from this plotting to be representative of good agreement when
more than 95% of the sample was within its limits (± 1.96 standard deviation in relation to the
average).(14)
The study met the national and international
standards concerning ethics in research involving
human subjects.
Results
A total of 830 new hospitalizations were observed
in the PICU during the study’s period. There were
13 admissions concerning newborns aged less than
28 days old that were not included: 12 in the postoperative period of cardiac surgery and one on mechanical ventilation due to bronchiolitis. Hence,
817 admissions were eligible. Data from one patient
(0.12%) were lost. A total of 816 hospitalizations
composed the sample and generated 7,702 observations for the measures.
The median age was 23.47 (5.7-72.2) months;
most were males (56.9%) and remained hospitalized less than seven days (65.4%). A total of 608
patients (74.3%) presented one or more organic
dysfunctions during the hospitalization. The most
prevalent dysfunctions were respiratory (45.6%),
followed by neurological (19.4%) and cardiologic
dysfunctions (17.2%).
In regard to their origin, 56.1% came from the
study’s hospital (surgical center and nursing ward)
and 43.9% came from the emergency department
or from another hospital; 58% were clinical patients
and 46% required mechanical ventilation.
As shown in Table 1, the scores obtained on the
TISS-28 during hospitalization ranged from six to
52, with an average of 19.2 ± 7.4 and a median of
18. On the day of the highest score (the maximum
TISS-28), the TISS-28 ranged from six to 59, with
an average of 21.3±8.2 and a median of 23. For all
Acta Paul Enferm. 2013; 26(2):123-9.
125
the averages of observations, TISS-28 was below
NEMS (p<0.001). The NEMS scores at admission
ranged from six to 48, with an average of 24.7 ±
8.2 and median of 23. The maximum NEMS score
ranged from six to 51, with an average of 26.6 ±
9.2 and a median of 25. PRISM had a good performance with expected mortality of 6.9% while
the observed rate of mortality was 6.6%. The SMR,
ratio of the observed by the predicted mortality was
0.96 (CI95%).
Table 1. Comparison of TISS-28, NEMS and Outcome of
patients hospitalized in Pediatric Intensive Care Unit
Characteristics
Total
n=816
PRISM<10
n=700
PRISM>10
n=116
p-value
TISS-28 during
hospitalization
19.2 ±
7.4
18.5 ± 7.2
23.7 ± 6.9
<0.001*
Maximum TISS28
21.3 ±
8.2
21.1 ± 8.2
22.47 ±
7.9
0.117
NEMS during
hospitalization
24.7 ±
8.2
24.5 ± 8.2
26.2 ± 8.2
0.036*
Maximum NEMS
26.6 ±
9.2
26.4 ±
9.22
28.0 ± 9.1
0.084
Expected
mortality
(PRISM)
56.2 6.9
21.2 3.0
35.0 30.2
<0.001*
Observed
Mortality
54.0 6.6
24.0 3.4
30.0 25.9
<0.001*
Legend: The TISS-28 and NEMS variables are expressed by averages and
standard deviation (average ± SD); The variables Expected Mortality and
Observed Mortality are expressed by an absolute number followed by
percentage – n(%); The symbol (*) indicates p<0.05; TISS-28 – Therapeutic
Intervention Scoring System-28; NEMS – Nine Equivalents of Nursing
Manpower use Score; PRISM – Pediatric risk of mortality score; Student’s t test
The NEMS and TISS-28 showed good discrimination of mortality when applied at admission
[AUROC of 0.71 (CI95% 0.63 - 0.78) and 0.68
(CI95% 0.60 - 0.75), respectively]; and maximum
scores [AUROC of 0.80 (CI95% 0.74 - 0.85) and
0.76 (CI95% 0.70 - 0.82), respectively]. Correlation among the indexes was good, both at admission (r2=0.70) and in relation to the maximum
score (r2=0.74) (p<0.01).
126
Acta Paul Enferm. 2013; 26(2):123-9.
The 816 studied patients were hospitalized from
one to 277 days, with a median of five (three-ten)
days, and totaling 7,702 observations. Including all
the measures, the TISS-28 ranged from two to 59,
with an average of 19.3 ± 6.6 and a median of 19.
The NEMS ranged from zero to 51, with an average
of 24.3 ± 8.2 and a median of 27.
Comparison between the NEMS and TISS-28
showed that the difference between the scores was
5 ± 4.45 (CI95% 4.9 - 5.1). The limit of agreement
for two standard deviations was from -3.9 to +13.9
(Figure 1). The difference between the scores that
were larger than two standard deviations (>8.9 DP)
was 6.2%.
Figure 1. Bland & Altman plotting for the agreement between
the NEMS and TISS-28 in a Pediatric Intensive Care Unit, Porto
Alegre, RS, Brazil; SD – Standard Deviation; Dif – difference;
NEMS – Nine Equivalents of Nursing Manpower use Score;
TISS-28 – Therapeutic Intervention Scoring System-28
Good correlation was found between the NEMS
and TISS-28 despite the difference between the two.
The correlation between the analyzed scores was
linear and positive (r=0.825; r2=0.704, p<0.001).
When customization was performed using binary
logistic regression, the relationship between the two
systems was NEMS = 4.25 + (1.04 x TISS-28).
When the sample was stratified, we observed
that the difference between the NEMS and TISS28 persists within a small interval of 3.6 points (2.4
to six), which would not justify a new customization (Table 2).
Table 2. Main characteristics of a sample from a Pediatric
Intensive Care Unit stratified according to the total number of
measures taken and averages obtained from NEMS and TISS28 and their statistical difference
Total
TISS-28
NEMS
Difference
n(%)
Average
± SD
Average
± SD
Average
± SD
Total
7,702(100)
19.3 ± 6.6
24.3 ± 8.2
5.7 ± 1.6
Infants
4,269(55.4)
20.4 ± 6.1
26.2 ± 7.7
5.8 ± 1.6
Children
3,433(44.6)
17.8 ± 6.9
21.9 ± 8.1
4.1 ± 1.2
TI < 7
1,987(25.8)
15.5 ± 6.2
19.7 ± 6.9
4.3 ± 0.7
TI > 7
5,715(74.2)
20.6 ± 6.2
25.9 ± 8.0
5.3 ± 1.8
Clinical
5,725(74.3)
19.8 ± 6.4
25.7 ± 7.9
5.9 ± 1.6
Surgical
1,977(25.7)
17.8 ± 7.0
20.3 ± 7.5
2.4 ± 0.5
Hospital
origin
3,127 (40.6)
18.0 ± 6.6
21.6 ± 7.7
3.6 ± 1.1
External
origin
4,575(59.4)
20.2 ± 6.5
26.2 ± 8.0
6.0 ± 1.5
Male
4,431(57.5)
19.4 ± 6.2
24.6 ± 7.9
5.2 ± 1.6
Female
3,271(42.5)
19.1 ± 7.0
23.9 ± 8.5
4.8 ± 1.5
Death
841(10.9)
23.7 ± 5.5
29.6 ± 7.1
5.9 ± 1.5
Alive
6,861(89.1)
18.7 ± 6.5
23.7 ± 8.0
4.9 ± 1.6
On
ventilation
5,585(72.5)
21.3 ± 6.2
27.0 ± 7.8
5.8 ± 1.6
Not on
ventilation
2,117(27.5)
14.1 ± 4.5
17.2 ± 3.6
3.1 ± 0.9
Legend: All the measures of averages between thee NEMS and TISS-28 were
different (p<0.001); NEMS – Nine Equivalents of Nursing Manpower use
Score; TISS-28 – Therapeutic intervention Scoring System-28; SD – standard
deviation; TI – duration of hospitalization in days; Student’s t test
Discussion
This independent study was conducted in a Pediatric
Intensive Care Unit to compare the scores obtained
by children and adolescents in the application of the
NEMS and TISS-28. The data collected enabled
customization for the computation, based on the
NEMS, of the score obtained in the TISS-29.
This study presents a limitation due to the fact
that data were collected in a single PICU, though
it favors the uniformity of data. It is also important
to consider that data were collected only once, between the morning and the afternoon. Some studies
collect data on three shifts but choose the highest
value or the average.(10) Additionally, the TISS-28
and NEMS do not consider the time nurses spend
with care provided to the family (assistance and
guidance). In this context, other scores such as the
Nursing Activities Scores should be verified.(15)The
median age found in this study was children younger than two years old while most were male. Other
studies report a higher percentage at an older age in
relation to the age of the sample in intensive care,
that is, 44.3 months(12) and 8.5 years old in international study.(16) Similar results concerning gender
were also verified in an epidemiological study conducted in a PICU.(17)
Aiming to compare the diagnoses that resulted
in hospitalization in a PICU according to organic
dysfunction, we verified in the literature differences
with a greater proportion of cardio-circulatory dysfunctions (30%) followed by respiratory (27%) and
neurological (22%) dysfunctions.(12) Respiratory
dysfunctions predominated in this study.
Considering the progression of patients over
the course of their hospitalization in the Pediatric
Intensive Care Unit, the scores obtained on both
the TISS-28 and the NEMS by the patients who
died were always higher than those obtained by the
survivors. More severe patients require a greater
number of therapeutic interventions, which is also
related to a heavier nursing workload.(18) The finding that patients who do not survive obtain higher
scores has also been verified in other studies.(18-21)
When the PRISM was higher than ten, mortality was 25.9%, and when the PRISM was lower
than ten, the mortality observed was 3.4%. The averages of the NEMS and TISS-28 for patients who
obtained a PRISM>10 was also higher when related
to length of hospitalization.
The AUROC was 0.80% for the score obtained
on the NEMS. This means that a patient who ends
up dying obtains higher scores on the NEMS than
a survivor 80% of the time, considering the maximum score obtained on the NEMS. Therefore, as
already observed with the TISS-28,(22) the NEMS
shows a good ability to discriminate mortality
during hospitalization and also when the maximum
scores of the indicators are considered.
Acta Paul Enferm. 2013; 26(2):123-9.
127
During clinical progression, we observed that
94.4% of the patients were discharged from the
PICU and 6.6% died; this finding is close to the
mortality indicators reported in international studies conducted in PICUs.(23) This information differs
from studies in the pediatric field conducted in Brazil, which report higher mortality rates in pediatric
intensive care.(24)
We observed that the NEMS and the TISS28 presented good agreement. A series of changes in the TISS-28 have been proposed in the progressive process of these scores that aims to assess
the severity of patients through the therapeutic
interventions to which they are subject, in addition to assessing the workload in ICUs.(2,25) Taking into account that one point on the TISS-28
is equivalent to approximately 10.6 minutes(2,26)
of a nurse’s work during his/her shift, these
scores are appropriate to discuss work processes
in order to adapt resources to the needs of intensive care units.
The NEMS overestimated the value of the
TISS-28 in all the studied variables. One of the
most important contributions of this study was the
finding that when one decreases approximately four
to five points in the NEMS’s score, one finds a result that is very close to the TISS-28’s score. The
equation found for the customization [NEMS =
4.25 + (1.04 x TISS-28)] was very similar to that
of a study conducted with adults.(10) There are few
studies in the pediatric field using scores to study
therapeutic interventions.(5)
It was possible to customize the NEMS and
TISS-28 scores for a Pediatric Intensive Care
Unit. In general, the TISS-28 is conceived as reflecting the nursing workload in a broad range
of levels of activity. The NEMS, however, has a
more attractive performance, as shown in this
study, and contains only nine therapeutic interventions, which demands less time for data collection. The use of the NEMS in PICUs is useful
for pediatric intensive care nurses, since it helps
to measure the severity of patients’ conditions
and their nursing care needs, in accordance with
Resolution 7/2010, National Agency for Sanitary Vigilance.(27)
128
Acta Paul Enferm. 2013; 26(2):123-9.
Conclusion
This study enabled the validation of the NEMS in
a Pediatric Intensive Care Unit of a University Hospital. We observed that the more therapeutic interventions, the higher the scores obtained and, consequently, the more severe the patient’s condition.
A good correlation was found between the TISS28 and the NEMS in this population of pediatric
patients, and both presented good discriminatory
capacity for mortality and good association with the
PRISM. However, the NEMS overestimated the
TISS-28 values for all the studied variables, which
enabled obtaining a customized computation between the scores.
Acknowledgments
To the National Council for Scientific and Technological Development (CNPq; research grant on
productivity A1 for PCR Garcia; research grant on
productivity A2 for JP Piva) and to the Coordination for the Improvement of Higher Education Personnel (CAPES; Master’s scholarship).
Collaborations
Canabarro ST and Garcia PCR participated in the
project’s conception, analysis and interpretation of
data, redaction, critical review of intellectual content and final approval of the version to be published. Velozo KDS contributed to the analysis and
interpretation of data, redaction, critical review of
the intellectual content and final approval of the
version to be published. Eidt OR participated in
the project’s conception, critical review of intellectual content and final approval of the version to be
published. Piva JP collaborated with data analysis,
critical review of intellectual content and final approval of the version to be published.
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Acta Paul Enferm. 2013; 26(2):123-9.
129
Original Article
Maternal age and factors associated
with perinatal outcomes
Idade materna e fatores associados a resultados perinatais
Angela Andréia França Gravena1
Meliana Gisleine de Paula1
Sonia Silva Marcon1
Maria Dalva Barros de Carvalho1
Sandra Marisa Pelloso1
Keywords
Maternal age; Pregnancy outcome;
Risk factors; Pregnancy complications;
Information systems
Descritores
Idade materna; Resultado da gravidez;
Fatores de risco; Complicações na
gravidez; Sistemas de informação
Submitted
January 17, 2012
Accepted
April 9, 2013
Angela Andréia França Gravena
Celso Garcia Cid highway, Pr 445 Km
380, Londrina, PR, Brazil. Zip Code
86.057-970
[email protected]
130
Acta Paul Enferm. 2013; 26(2):130-5.
Abstract
Objective: To analyze and compare perinatal outcomes of pregnant adolescent women and pregnant women
in later age (between 20 and 34 years old) from data of a Live Born Information System.
Methods: A cross-sectional study was carried out with data collected retrospectively of 18,009 live born
infants from consults of data of a Live Born Information System. Registers of live born infants were distributed
in three groups: group I (adolescents) – 10 to 19 years old; group II – 20 to 34 years old; and group III (later
age) – 35 years or older.
Results: Findings showed that perinatal risks were related to prematurity (OR 1,35) and five-minute Apgar
scores of less than seven (OR 1,44) among infants born to adolescent mothers.
Conclusion: Results pointed out high indexes of preterm birth in low-birth-weight infants and five-minute
Apgar scores of less than seven in pregnancies that occurred in adolescents and in women 35 years and older.
Resumo
Objetivo: Analisar e comparar os resultados perinatais de gestantes adolescentes e em idade tardia com
mulheres entre 20 a 34 anos, a partir dos dados do Sistema de Informação de Nascidos Vivos.
Métodos: Foi realizado um estudo transversal, com coleta de dados retrospectiva de 18009 nascidos vivos a
partir de consultas aos dados do Sistema de Informação de Nascidos Vivos. Os registros dos nascidos vivos
foram distribuídos em três grupos: grupo I (adolescentes) – 10 a 19 anos; grupo II - 20 a 34 anos e grupo III
(idade tardia) – 35 anos ou mais.
Resultados: Os resultados mostraram riscos perinatais relacionados à prematuridade (OR 1,35) e Apgar
quinto minuto menor que sete (OR 1,44) em mães adolescentes. O baixo peso ao nascer apresentou risco de
1,22 e 1,24 vezes entre as gestantes do grupo I e III.
Conclusão: Os resultados apontaram elevados índices de nascimento pré-termo, baixo peso ao nascer e
Apgar no quinto minuto menor que sete nas gestações ocorridas em adolescentes e em mulheres com idade
igual ou superior aos 35 anos.
Universidade Estadual de Maringá, Maringá, PR, Brazil.
Conflicts of interest: the authors have no relevant conflicts of interest to disclose.
1
Gravena AAF, Paula MG, Marcon SS, Carvalho MDB, Pelloso SM
Introduction
Methods
It is estimated that one in four births in Brazil occurs among adolescents 15 to 19 years old.(1) International studies report that one third of all American girls will become pregnant by the time they are
20 years old.(2) Data indicate that besides the relative increase in pregnancy among adolescent women, the same increase occurs among women older
than 30 years.(3)
Studies have suggested that adolescents and
women 35 years or older are often vulnerable to
perinatal adverse results and maternal morbidity
and mortality.(4-6) Among women between 15 and
19 years old, the risk for death related to pregnancy
or delivery complications is two times higher than
in women older than 20 years.(7)
Adolescent pregnancy, especially in early adolescence (< 15 years old), requires special attention
to possible injuries to maternal and fetal health.
Increased risks for low-birth-weight newborns, micronutrient deficiencies, and intrauterine growth
restrictions are related to early pregnancy. Such facts
have led to changes in the evolution of gestation
and in fetal growth and may also result in premature labor (ie, < 37 weeks of gestation).(4)
Prematurity has been studied as a cause of death
among children. Premature newborns have incomplete development of organs such as the brain and
lungs; in addition, they present with limited renal
and hepatic function, which could cause serious
compromising adverse outcomes.(8)
In women with late gestation, more spontaneous and induced abortions have been seen, as well
as increased risks for perinatal mortality, low vitality
of the newborn, low birth weight, preterm delivery,
and a small-for-gestational-age fetus.(9) Gestation of
women with advanced maternal age has been considered a high risk factor, mainly for the growing
incidence of hypertensive syndromes, premature
rupture of membranes, diabetes, and a higher risk
for a five-minute Apgar score of less than seven.(10)
This study analyzed and compared perinatal
results of pregnancy in adolescent women and in
women between 20 and 34 years old from data collected from a Live Born Information System.
This cross-sectional and retrospective study is composed of 18,009 records of the Live Born Information System (SINASC, acronym in Portuguese). The
study was carried out in Maringa, Parana, south of
Brazil, from January 2007 to December 31, 2009.
Records classified as “ignored” and “not informed”
were excluded, which totaled 58 records.
Information concerning gestational age was divided into groups: group I (adolescents between 10
and 19 years old), group II (young adults between
20 and 34 years old), and group III (adults ≥35
years; late age).
Maternal variables analyzed were maternal age,
marital status, years of formal education, and the
number of prenatal and parity visits.
Concerning perinatal results, the following
variables were analyzed: type of delivery (vaginal vs
cesarean section), gestational age, newborn weight,
and five-minute Apgar index.(11-12)
The frequencies of variables in the adolescent
group (group I) and the advanced age group (group
III) were compared with the respective frequencies
in the group composed of women between 20 and
34 years old (group II).
For data analysis, we applied the X2 test using
the statistical program 7.1. To determine association strength, we calculated an odds ratio (OR)
and a confidence level of 95% (CI 95%) using
the Epi Info 3.5.1. Significance level was placed
in P<0.05.
Development of this study followed national
and international ethical and legal aspects of research on human subjects.
Results
Of 18,009 records that comprised the study population, 2,161 infants (12,0%) were born alive
from adolescent women; 13,394 (74.4%) from
young adult women; and 2,454 (13.5%) from
late-age women.
Regarding maternal characteristics, we observed
that between adolescents and advanced-age womActa Paul Enferm. 2013; 26(2):130-5.
131
en (women ≥35 years old), the proportion of those
who had seven years of formal education was higher
compared with group II (Table 1).
Table 1. Distribution of maternal characteristics and perinatal
results according to maternal age
Maternal age (years)
Characteristics
10-19
20-34
≥ 35
n(%)
n(%)
n(%)
Up to 7 years
660(30.6)
1539(11.5)
396(16.1)
≥ 8 years
1497(69.4)
11852(88.5)
2057(83.9)
Single
1730(80.1)
4964(37.1)
664(27.1)
Marriage
429(19.9)
8426(62.9)
1790(72.9)
None
1880(87.0)
6927(51.7)
646(26.3)
1-3
281(13.0)
6278(46.9)
1730(70.5)
-
189(1.4)
78(3.2)
<4
138(6.4)
355(2.6)
50(2.0)
4-6
572(26.5)
1950(14.6)
325(13.3)
1449(67.1)
11069(82.8)
2078(84.7)
Preterm
319(14.7)
1523(11.4)
314(12.8)
Term
1834(84.9)
11848(88.5)
2135(87.0)
7(0.4)
21(0.1)
4(0.2)
Cesarean section
1300(60.2)
10800(80.7)
2147(87.5)
Vaginal
861(39.8)
2591(19.3)
307(12.5)
Low birth weight
266(12.3)
1385(10.3)
306(12.5)
Normal
1895(87.7)
12009(89.7)
2148(87.5)
66(3.1)
266(2.0)
54(2.2)
2092(96.9)
13118(98.0)
2399(97.8)
Years of formal
education (*)**
Marital status
(*)***
Number of
children****
≥4
Prenatal visit
(*)*****
≥7
Gestational age
(*)******
Post-term
Delivery
(*)*******
Born weight
********
Five-minute Apgar
index *********
Low
Normal
Source: SINASC, Maringá, PR, 2007-2009
Legenda: (*) Variable information classified as “ignored” and “not informed”
were excluded, which was implicated in minor losses of 10% for each variable;
**n=18001; ***n= 18003; ****n=18009; *****n=17986; ******n=18005;
*******n=18006; ********n=18009; (*)*********n=17995
132
Acta Paul Enferm. 2013; 26(2):130-5.
We also observed that the rate of cesarean deliveries increased with advancing maternal age, which
showed a higher proportion of low-birth-weight
newborns and premature infants born to adolescent
women and to women with advanced maternal age.
Analysis of maternal characteristics and perinatal adverse results using the OR verified that pregnant adolescents were more likely to be single. Pregnant women from 10 to 19 years old and those of
advanced age were more likely to have up to seven
years of formal education. Compared with the other groups, more mothers in the adolescent group
engaged in less than four prenatal visits (Table 2).
Pregnant adolescents also had increased risks for
delivery of a premature infant and delivery of an
infant with low five-minute Apgar index. Women
35 years or older had a high probability of cesarean
section delivery than adult women. Adolescent and
advanced-age mothers were more likely to deliver
low-birth-weight newborns (Table 2).
Discussion
Our study had some limitations. These limitations
involved a standardized public system that is deficient in information on formal education, marital
status, number of prenatal visits, gestational age,
type of delivery, and value of five-minute Apgar index, in which information on these variables is represented as ignored and not informed. Data about
pregnancy complications such as abortion and fetal
death, factors related to maternal age, and inadequacy of prenatal care were not studied because the
system does not include such data.
Despite several technological advances in medicine to reduce perinatal adverse outcomes, it is important to highlight that data found in this study
could be used by nursing services to inform and
counsel both adolescents who become pregnant and
women who intend to postpone pregnancy about
the risk for perinatal complications.
The adolescents in this study were characterized
as being single young women. Other researchers
have shown that a small proportion of adolescents
were married.(13) Published data have confirmed the
Table 2. Comparison of ratio of chance in studied population*
Characteristics
10 - 19
f
OR
IC 95%
660
3.4
3.05-3.78
Up to 7 years of formal
education
1497
Single mothers
1730
p-value
<0.001
138
Prenatal
2021
Preterm
319
6.85
6.11-7.66
<0.001
1300
2.5
2.04-3.08
<0.001
266
1.35
1.18-1.54
<0.001
1539
1.0
4964
355
1523
0.36
0.33-0.44
<0.001
10800
1.0
1.06-1.40
0.006
1385
OR
IC 95%
396
1.48
1.31-1.67
<0.001
0.46
0.41-0.50
<0.001
0.76
0.56-1.04
0.080
1.14
1.00-1.31
0.057
1.68
1.47-1.91
<0.001
1.24
1.08-1.41
0.001
664
1790
1.0
50
2403
1.0
314
2139
1.0
2591
1.22
p-value
f
2057
11869
1895
Five-minute Apgar index
lower than 7
OR
13019
861
Low birth weight
f
8426
1841
Cesarean section
≥ 35
11852
429
Less than 4 visits
20 - 34
2147
307
1.0
12009
306
2148
66
1.44
1.08-190
0.010
266
1.0
54
1.11
0.82-1.51
0.532
2092
13118
2399
Source: SINASC, Maringá, Pr, 2007-2009
Legend: f - frequency; OR - odds ratio; CI – confidence interval of 95%; *ratio of chances comparing cited groups such as pregnant women between 20 and 34 years old
prevalence of single women living without a partner
during adolescence.(5,14)
Adolescent pregnant women and women in advanced age had up to seven years of formal education. Maternal age and a lower level of formal education are associated with stillbirth and are assumed
special relevance because of their interrelationship
with other factors associated with fetal death. An investigation carried out in Recife showed a risk of 2.3
of fetal deaths in newborns in women with less than
eight years of education.(15) In pregnant adolescents,
early maternity is identified as a distancing factor
and is difficult to obtain in continuing studies. Research shows a rate of 25.8% of adolescents who did
not complete high school, which represents a social
problem in Brazil.(3)
The number of prenatal visits in our study was
in accordance with other similar studies done in
Brazilian regions that pointed out an association
(OR=2.03) between adolescents with a low number
of prenatal visits.(3,8) A study that identified pregnant adolescents’ behavior regarding prenatal visits
indicated “forgetting” as the main reason for not
following up with prenatal visits.(13) The number of
late first visits and irregular visits suggests the need
of the healthcare team to stimulate and motivate
these young mothers to keep up with prenatal visits.
We observed, especially among women older
than 35 years, a risk for cesarean section of 1.68
times higher than among women between 20 and
34 years old. A retrospective study conducted in
Taiwan of 39,763 women showed that the risk for
cesarean section was 1.6 times higher in women
between 35 and 39 years old and 2.6 times higher
in women 40 years or older.(11) It is important to
emphasize that the incidence of cesarean section deliveries in advanced-age pregnant women has been
reported in other studies.(6,10,12,16,17)
Several reasons may explain the high incidence
of cesarean section in women with advanced maternal age such as diseases, obstetric indications, and
fetal complications. Deterioration of myometrial
function with age is another factor responsible for
some delivery complications.(17)
Considering risks of newborns exposed, the
occurrence of preterm delivery in the adolescent
group in this study was 1.23 times higher. This risk
is in accordance with risks reported in other publications.(8,13,18) A Brazilian investigation showed that
prematurity was 1.46 times higher among pregnant
Acta Paul Enferm. 2013; 26(2):130-5.
133
adolescents.(10) The risk for preterm delivery in adolescents is related to the increase in subclinical infection and production of prostaglandins because of
uterine immaturity or inadequate blood supply to
the uterine cervix.(18)
Low birth weight was presented as a risk factor
in the extremes of reproductive life, with a prevalence of 12.3% and 12.5% and relative risks of 1.22
and 1.24 among adolescents and women older than
35 years, respectively. A retrospective study carried
out in Liverpool, Scotland, that included 9,506 records of births, observed a frequency of low birth
weight in pregnant adolescent women and in pregnant late-age women, respectively, which found the
presence of low birth weight in the extremes of reproductive life.(19) In an investigation of adolescent
mothers, the rates of low-birth-weight deliveries
increased consistently with younger maternal age.
These rates were higher in newborns of mothers 15
years or younger.(18)
Low birth weight is associated with an increased
perinatal mortality index and with a growth index under expectations for adolescent women and
women older than 35 years.(20) The incidence of
low-birth-weight newborns of women older than
30 years showed that the mean of birth weight decreased and the proportion of low-birth-weight and
extremely low-birth-weight infants increased with
advanced maternal age.(17)
Delivery of low-birth-weight infants in advanced-age women has also been identified in other
studies.(17,21) Among associated maternal factors, the
most emphasized are arthritis; chronic blood hypertension; depression; cancer; and acute myocardial
infarction, which constitute independent risk factors for fetal growth restriction.(16)
Newborns born to adolescent mothers were
1.44 times more likely to present with an Apgar index of lower than seven in the first five minutes. A
research study observed an association of extremely
low birth weight and low five-minute Apgar index
in children born to women younger than 18 years
old.(18) This index is a good indicator for long-term
perinatal results; in addition, it is considered an important predictor for assessment of well-being and
initial prognosis of the newborn.
134
Acta Paul Enferm. 2013; 26(2):130-5.
Conclusion
Results of our study have revealed high indexes of
preterm birth, low birth weight, and five-minute
Apgar score of lower than seven in children born to
adolescent women and women older than 35 years.
Collaborations
Gravena AAF analyzed and interpreted the data,
drafted the paper, and performed critical review of
the paper. Paula MG designed the project and drafted the manuscript. Marcon SS; Carvalho MDB and
Pelloso SM performed a critical review relevant to
the intellectual content of the manuscript. All authors approved the final proofs to be published.
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Acta Paul Enferm. 2013; 26(2):130-5.
135
Artigo Original
Challenges for the management of emergency
care from the perspective of nurses
Desafios para a gerência do cuidado em emergência
na perspectiva de enfermeiros
José Luís Guedes dos Santos1
Maria Alice Dias da Silva Lima2
Aline Lima Pestana1
Estela Regina Garlet2
Alacoque Lorenzini Erdmann1
Keywords
Nursing administration research;
Nursing service, hospital; Nursing care;
Management; Emergency nursing
Descritores
Pesquisa em administração de
enfermagem; Serviço hospitalar
de enfermagem; Cuidados de
enfermagem; Gerência; Enfermagem
em emergência
Submetted
March 3, 2012
Accepted
February 21, 2013
José Luís Guedes dos Santos
Servidão Donato José Alves street,
95/4, Córrego Grande, Florianópolis,
SC, Brazil. Zip Code: 88037-415
[email protected]
136
Acta Paul Enferm. 2013; 26(2):136-43.
Abstract
Objective: To analyze the challenges for the management of care in a hospital emergency department, based
on the perspective of nurses.
Methods: A qualitative, descriptive and exploratory study, conducted from June to September 2009, through
semi-structured interviews with 20 nurses in the Emergency Department of a university hospital in southern
region of Brazil. Data were analyzed using thematic analysis.
Results: The main challenges of nursing in managing care in emergency units were: management of
overcrowding, maintaining quality of care, and utilization of leadership as a management tool. The suggestions
mentioned to overcome these were: reorganization of the health system to focus on emergencies, changes in
the flow of patient care, and implementation of training on nursing management.
Conclusion: Such challenges and strategies represented a boost to the development of new practices through
collaborative and coordinated work with the emergency care network.
Resumo
Objetivo: Analisar os desafios para a gerência do cuidado em um serviço hospitalar de emergência, com base
na perspectiva de enfermeiros.
Métodos: Pesquisa qualitativa, do tipo descritiva e exploratória, realizada de junho a setembro/2009, por meio
de entrevista semiestruturada com 20 enfermeiros do Serviço de Emergência de um Hospital Universitário da
Região Sul do Brasil. Os dados foram analisados mediante análise temática.
Resultados: Os principais desafios dos enfermeiros na gerência do cuidado em emergência foram
gerenciamento da superlotação, manutenção da qualidade do cuidado e utilização da liderança como
instrumento gerencial. As sugestões citadas para superá-los foram reorganização do sistema de saúde para
atenção às urgências, alteração no fluxo de atendimento dos pacientes e realização de capacitação sobre o
gerenciamento de enfermagem.
Conclusão: Tais desafios e estratégias representam um impulso para o desenvolvimento de novas práticas por
intermédio de um trabalho colaborativo e articulado com a rede de atenção às urgências.
Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.
Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
Conflict of interest: there are no conflicts of interest to declare.
1
2
Santos JLG, Lima MADS, Pestana AL, Garlet ER, Erdmann AL
Introduction
The organization of care and the management of
care provided to patients in hospital emergency services are issues discussed in various countries, due
to the epidemiological and demographic transition
of the world’s population. The longer life expectancy of the population and increased morbidity
and mortality from cerebrovascular and coronary
diseases, for example, are factors that have contributed to the increased rates of demand for care in
those services, and encouraged the discussion about
the need for adoption of new care models in order to provide more complex and prolonged care.
(1,2)
In Brazil, the National Policy for Care in Emergencies, established in 2006 and updated in 2011,
states that the care for users with acute conditions
must be provided at all ports of entry for services
of the Unified Health System, enabling the resolution of integral problems or transfering those clients, responsibly, to a more complex service, within
a hierarchical and regulated system, organized into
regional networks of care for emergencies as links in
a network of maintaining life in increasing levels of
complexity and responsibility.(3)
However, emergency hospital services continue
to be the place where unresolved or undiagnosed
problems at other levels of care converge. For the
largest parts of the population who do not have regular access to health care service, hospital emergency rooms are the main alternative of care for the
most diverse situations, because in a common sense,
these services gather resources that make them more
resolute, namely consultations, medicine, nursing
procedures, lab tests and hospitalizations.(4,5) As
a consequence, it is observed that chaotic utilization, the overcrowding of emergency services, and
the lack of hospital beds cause several difficulties of
care, both for patients and the healthcare team.(2,4)
Specifically regarding the nurses’ performance in
care management for an emergency department, we
highlight the need for a constant search for development of better strategies to enable them to overcome
the challenges imposed by working in an environment characterized by the constant demand for care.
Earlier studies have identified that management is an
essential activity and predominant work of nurses in
emergency services. It is up to these professionals to
search for means to ensure the availability and quality
of material and infrastructure resources for the team
to operate for the care of patients with complex needs,
visualizing not only the needs of the patient, but also
reconciling organizational objectives and those of the
nursing team, establishing interfaces with other hospital departments and the local health system, aimed
at the production of comprehensive, effective and safe
care.(5-8) Furthermore, informally, there are nurses who,
many times, negotiate daily the resolution of internal
and external problems of emergency work, which enables the proper functioning of the service.(2)
To achieve these objectives, the nurses in emergency units should combine control of time, theoretical foundation, discernment, initiative, maturity,
emotional stability and leadership ability, which requires the development of skills such as communication, interpersonal relationship and decision making.(7) Leadership is a fundamental management tool
for nursing work; because it coordinates the nursing
work and mediation between the different professionals of the health team, it can be learned and developed, where there is interest and initiative.(9)
Based on the above, we point out the importance of conducting a study about the challenges
experienced by nurses in emergency care management, and their suggestions for addressing them
and exercising a professional practice grounded in
ethical, humanistic, and scientific principles guiding the practice of nursing. Thus, research questions
were established: What are the challenges of nurses
in care management of a hospital emergency department? What suggestions are proposed by them to
overcome those challenges?
Thus, this study had as its objective to analyze
the challenges for the care management in a hospital emergency department, guided by the perspective of nurses.
Methods
This was a qualitative, exploratory and descriptive
study, whose data were collected in the emergency
Acta Paul Enferm. 2013; 26(2):136-43.
137
Challenges for the management of emergency care from the perspective of nurses
department of a university hospital located in the
southern region of Brazil.
Data collection occurred between June and
September of 2009, through semi-structured interviews with 20 of the 32 nurses who worked in
the section. The guiding questions focused on the
challenges faced in the care management of a hospital emergency department, and suggestions to
overcome these. An intentional sample was defined,
and involved the selection of subjects considered
representative according to interest in the investigated issue and the study objectives. Thus, we included nurses who agreed to participate and had
worked for more than six months in the emergency
department. For the definition of this period, we
considered six months as a long enough time for
adaptation of the professional to the sector routines
and teamwork, in this way, contributing more effectively to the investigation.
The interviews were recorded using an electronic audio device, totaling between ten to 50 minutes,
and were then transcribed. The number of interviews conducted was defined based on the criterion
of data saturation, i.e., when the information obtained began to repeat itself, enabling the identification of convergences and the establishment of a
linkage between the evidence.
For data analysis, the content analysis technique
was used, of a thematic analysis type, which consists
of three steps: pre-analysis, material exploration and
data processing, inference and interpretation.(10) In
the pre-analysis phase, by means of floating reading, the main ideas of the collected material were
organized and systematized based on the criteria
of exhaustiveness, representativeness, consistency
and relevance. After that, we proceeded to the exploration of the material in order to highlight the
registry units, transforming raw data into nuclei of
understanding of the text and the construction of
empirical categories. In the final phase, we proceeded to the processing and interpretation of results.
Through coordination between the empirical structured material and the literature, three thematic categories emerged that composed the theme: Challenges in the management of care and suggestions
for overcoming them.
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Acta Paul Enferm. 2013; 26(2):136-43.
The development of the study followed national
and international standards of ethics in research involving humans.
Results
The results are presented in three categories: management of overcrowding, maintaining quality of
care, and use of leadership as a management tool.
Management of overcrowding
Management of overcrowding is a challenge for
nurses, as they need to plan the implementation of
care and to organize work, adapting to the conditions of care available, to the amount and severity of
the patients’ clinical symptoms, in order to achieve
the best possible care, against a backdrop marked
by constant demand for care, as evidenced in the
following statement:
“[...] The management of overcrowding, the excessive number of patients with our conditions [...]
I like to have the unit as organized as possible within the disorganization of emergency, people live and
I live with it, always trying to minimize it, but it is a
sector that in a little while gets 20, 60, 100 patients,
and you’re seeing things, one patient above the other and so on [...]”. (E1).
Among the reasons that cause overcrowding of
emergency services, nurses highlighted the constant
demand for care of low-risk patients, burdening
the nursing staff and making the care of more ill
patients difficult. In this way, some nurses demonstrated being critical in relation to the ignorance
of people about the purpose of the department to
handle actual emergencies and a lack of patience for
those seeking primary health care:
“One of the main challenges is overcrowding,
mainly due to the care of those patients that are not
urgent” (E13).
“[...] I have trouble understanding, why people
cannot define that this is an emergency service, and
they must avoid coming due to neck pain, ingrown
toenails, and abdominal pain. This is a cultural issue
of the people that do not work. Only that is not
quite all, there are the people who no longer want
to subject themselves and wait, because they come
here and can do everything, like, x-ray, blood tests,
and they don’t need to run from one side to another
[...]”. (E15).
To avoid the overcrowding, the nurses suggested
a reorganization of the entire healthcare system in
order to receive less complex urgent care patients in
the basic units and health centers.
“It is the entire network that has to change, not
just in here. We cannot try to do a better job while
the network does not change”. (E10).
“[...] the health system is poor, if we had
a good service at the heath center unit, a
lot of people would not come here”. (E14).
“It has to improve the health system as a whole, primary care treating the less critical patients and we
can work with more tranquility.” (E20).
Maintaining the quality of care
Overcrowding poses a challenge to the maintenance of quality of care provided to patients in the
emergency department. Many patients, after the
first care and stabilization of their clinical condition, stay in the emergency department and require
attention that does not always correspond to the
nursing team, according to the characteristics of the
work unit, as reported by the respondent:
“Emergency care provides very good care, but
the continuity of this is complicated. The right
thing would be for the emergency department
to give the first care and refer patients, but they
end up staying, and we cannot provide adequate
care” [...]. (E8).
The realization of care related to hygiene and
comfort of patients who stay for observation is the
principal difficulty faced by nurses and the nursing
staff, considering the excessive number of patients
and inadequate physical space of emergency service rooms. Accordingly, the quality of care provided in observation rooms of emergency service
concerns nurses:
“No matter whether we have sufficient material,
if the unit is organized, if the number of technicians in the schedule is correct, they, at times, leave
the patient’s side. Yesterday, I had a patient in poor
clinical condition with prescription for airway suc-
tioning. I looked to the wall and did not have a
suction cannister, so I looked for a cannister, tube,
sleeve, and all the material and I said to the technician: “Look at this patient’s mouth,” I showed her
there was a crust. With the overcrowding, people
forget to do what seems insignificant, but, what is
essential”. (E17).
With suggestions for seeking a higher quality
of care in the emergency department, the nurses
mentioned the need for change in the patient care
flow and the expansion of the physical structure of
the emergency service. Regarding the change in the
flow of patient care, nurses highlighted the importance of expediting the hospital admissions and release of patients:
“What could be expedited is the issue of hospitalization and discharge of the patients, this is something
that depends a lot on the medical staff [...]” (E12).
“[...] I would like, that here in emergency, the
service was truly urgency and emergency, because
90% of patients who are in the observation room
would be in inpatient units” (E15).
“Reducing the number of patients in the unit,
but this doesn’t depend on nursing, it depends on the
patient flow from triage to the speed of discharge or
transfer of the patient to hospital admission” (E19).
To streamline the flow of patient care, nurses recognized the need for participation and collaboration of all professionals in the health team,
especially the physicians. However, in one of the
statements, there was a suggestion that patient
admission should be managed by nurses because
of their experience and management training received, which gives them a broader view in relation to this issue:
“[...] It would be very interesting if a nurse had
the responsibility for the hospitalization of patients,
not a physician and secretary. Nurses have a global
view of this, experience and management training
to make things go faster” (E12).
With regard to the enlargement of the physical
structure of the emergency service, the study participants indicated, as a strategy, the need for a greater
number of stretchers to accommodate patients.
“On the physical side, our biggest problem is
the lack of stretchers [...]” (E9).
Acta Paul Enferm. 2013; 26(2):136-43.
139
“There is a lack of better beds, because there are
a lot of stretchers that are broken” (E13).
“[...] The stretcher issue stresses me very much!
It’s a stress when the patient gets ill, is hypotensive
and we don´t have a stretcher or when we have to
remove a patient from there to accommodate another patient” (E15).
Use of leadership as a management tool
To program and implement changes, in order
to improve the care in the emergency department,
leadership emerges as an important management
tool for nurses. Practicing it is a challenge for them,
in relation to the resistence of the nursing and
health staff facing the proposition of new actions:
“A challenge that exists is the question itself of
being more of a leader, because many people who
are in here think that this is not right, but they say
that it’s always been like that, it doesn’t make sense
to do anything. I do not believe this, because if I
come here, it is to work” (E8).
For this interviewee, many professionals, particularly those who have been at the institution a longer time,
are reluctant to change, even when it can bring benefits
to the unit and themselves as workers, which makes
the performance of nurses as the leader of a nursing
staff more difficult. Conscious of the challenges that
involve leadership in the emergency department, the
nurses mentioned as a suggestion the completion of a
training course about nursing management.
“The ideal would be a course about people
management with an expert, to come here and
pass that knowledge on to us, for us to put it more
into practice“ (E3).
The realization of training focusing on nursing
management is an interesting strategy, in view of
the increasing importance of acquiring a managerial dimension in the work of the nurse in health
services, and how quickly new knowledge has been
produced in this area.
Discussion
This research provides subsidies for nurses, health
professionals and managers of emergency services to
140
Acta Paul Enferm. 2013; 26(2):136-43.
reflect on their practices and invest in the development / refinement of strategies to improve the quality of emergency care and the working conditions
for health care staff.
This study presents as a limitation the results of
the exclusive focus on the nurses. Managing care is a
collective process, the implementation of the suggestions presented requires acting in combination with
the nursing and health care staff, which leads to the
recommendation for research with these professionals in order to add new perspectives and opinions
to the possibilities for solving the problem of overcrowding and contributing to the quality of care.
In the words of the nurses, overcrowding appears as a characteristic incorporated into the work
process in the emergency department. Accordingly,
they mentioned the need to minimize and manage
it, looking for conditions to provide adequate and
humanized care to patients. This may be related to
naturalization of the pressure of a humanized working environment for health professionals and the
lack of control over their practice, which makes the
professional, often, intuitive.(2)
Overcrowding is linked to the concept of users who seek care in emergency departments when
there is an urgent need. Rather than waiting on
health professionals, users seek care when presenting health changes that they consider important.
Actually, there is a mismatch between what users
and health professionals think, regarding the purpose of the emergency department work.(11)
The difficulty of the healthcare team of patient
acceptance, which is seen as a product of the failure
of the network and inadequate for emergency care,
may be faced by humanization policies, strategies of
awareness and acceptance of emergency as the possible and legitimate gateway into the current healthcare system. Furthermore, it is important to discuss
how to integrate within the network this type of
patient to the other possible gateways and prepare
to serve them, since the demands are generated by
cultural factors and the deficiency of technological
and social resources.(12)
Another aspect highlighted by the study participants was a mischaracterization of the mission of the emergency service. The unit, which
should have a transitory character, where the patient would remain a short time, functions as an
inpatient unit, due to the unavailability of beds
in other hospital sectors. Therefore, meeting the
basic human needs, such as sleep, rest, food and
personal hygiene become compromised by excessive demand for treatment and due to the conditions of inadequate infrastructure for performing
care activities. This result is convergent with the
findings of previous studies in which structural
conditions were described as factors that hindered
quality care in emergency services.(7,13,14)
The retainment of patients after resolving their
urgent needs was a common problem in emergency
hospital services, which occurred due to the lack of
an institutional culture with a view to optimizing
the service regarding the management of vacancies,
among other factors.(13) Consequently, healthcare
professionals are faced with elevated workloads, inadequate physical spaces, and with insufficient material resources and equipment, which along with
compromising the quality of care delivered, causes
suffering, dissatisfaction and conflict.(15,16)
The reorganization of the healthcare system for
the care of urgencies of lower technological complexity was the suggestion of nurses to overcome
the challenge of overcrowding. This suggestion is
consistent with the principles governing the Unified Health System and is already a reality in other
settings. Fourteen years ago the region of Ribeirão
Preto began a process of organizing the flow of
emergency patients that evolved into an intermunicipal referral, and enabled the organization and
structuring of a regional health care network, hierarchical in attention to the emergency room, regulated through the implementation of Medical Regulation and the Mobile Emergency Care Service.(17)
Inserted into this scenario, the Emergency Room
of the Hospital das Clínicas of Ribeirão Preto, with
the support of clinical services linked to departments
of the University of São Paulo and the Center for
Studies of Emergencies, redefined its care and educational mission, addressing overcrowding with a
significant reduction in the number of consults and
the occupancy rate in the unit.(17) This experience
showed that through the joint efforts of professionals
and health services and the articulation of the spheres
of government, it is possible to overcome the dichotomies that characterize attendances to the emergency
room in Brazil.
Similarly, American studies(18,19) emphasize that
the search for quality of care in emergency services
should be planned at the regional level, through an
agency to coordinate the standardization of care and
referrals. In the specific field of services, we suggest
the development of triage protocols for faster care
and to increase the number of beds in intensive care
units in order to transfer the most severely ill patients.
Regarding the role of a nurse, it was observed
that this professional cannot develop sequenced
work due to excessive demand and the constant
requests, both by nursing staff, patients, and other
professionals, which clearly demonstrates insufficiency of these professionals and the lack of planning in the performance of their role.(13) These characteristics can justify the fact that nurses consider it
a challenge to exercise leadership in the emergency
department. Leadership in nursing, as well as being
a complex social phenomenon, is a fundamental instrument for care management that requires nurses’
commitment to the quest for continuous improvement of their skills and potential. For an effective
exercise of leadership, it is important that the nurse
be responsible, committed to the work of maintaining effective communication with the nursing team.
The challenges surrounding the management
of care in emergency are collective and need to be
conceptualized and discussed in the institutional
and political context in which they exist. Therefore,
it is important that the nurse glimpse the care of
nursing as a social entrepreneurial practice, seeking
to mobilize and integrate the different systems in a
functionally differentiated network perspective, increasing and multiplying individual competencies
and local resources aimed at creating an integrated
plan and individualized care for the development of
social policies, capable of understanding the complexity of factors involving human beings in their
real and concrete context.(21)
Specifically in relation to their performance in
the emergency department, the nurses suggested
that greater participation in the nursing manageActa Paul Enferm. 2013; 26(2):136-43.
141
ment of hospitalization and hospital beds could
contribute to management of overcrowding in
emergency units. Similarly, in the international
context, the hiring of nurses and the expansion of
their professional roles through advanced nursing
practice, ranging from the performance of triage
with risk classification to the clinical care provided to cases of minor technological complexity, have
contributed to the reduction of healthcare costs,
improving quality of care and reduction of waiting
time for care.(6)
Therefore, the challenges presented by nurses
who manage the emergency care reinforced the need
for being a creative, critical, and reflective professional to suggest actions related to the organization
and structuring of the unit and of the healthcare
system for emergency care. The need for advancements in the organization of the healthcare system
is undisputed, so that attention to urgent care can
be performed in other ports of entry. However, the
system will only be improved from the moment
each service and health worker recognizes and assumes its share of co-responsibility in the pursuit of
changes pointing to better resolution of the health
needs of the population.
More studies are needed that focus on the participation and integration of hospital emergency
services in an urgent care network, exploring the interfaces established with fixed and mobile pre-hospital service components with emergencies, and
identifying those aspects that require improvement
and discussion.
Conclusion
The main challenges that nurses were found to face
in the management of care in a emergency hospital service were the management of overcrowding,
maintaining the quality of care, and use of leadership as a management tool. As suggestions for overcoming these, nurses indicated the need for healthcare system reorganization to focus on emergencies,
changes in the flow of patient care, expansion of
the physical structure of the unit, and conducting
training on nursing management.
142
Acta Paul Enferm. 2013; 26(2):136-43.
Acknowledgements
Coordenação de Aperfeiçoamento de Pessoal de
Nível Superior (CAPES) for the Master’s education
grant, to the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq; process #
478895/2008-9) for the productivity in research
grant.
Collaborations
Santos JLG; Lima MADS; Pestana AL; Garlet ER
and Erdmann AL declare that they contributed to
the conception and design, analysis and interpretation of data, drafting the article, critically reviewing
it for intellectual content, and final approval of the
version to be published.
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Acta Paul Enferm. 2013; 26(2):136-43.
143
Original Article
Construction and validation of an instrument
for classification of pediatric patients
Construção e validação de um instrumento de
classificação de pacientes pediátricos
Ariane Polidoro Dini1
Edinêis de Brito Guirardello1
Keywords
Child care/classification; Health
evaluation; Pediatric nursing; Validation
studies; Workload
Descritores
Cuidado da criança/classificação;
Avaliação em saúde; Enfermagem
pediátrica; Estudos de validação; Carga
de trabalho
Submitted
March 25, 2012
Accepted
February 21, 2013
Ariane Polidoro Dini
Vital Brasil stwwreet, 251, Zeferino Vaz,
Campinas, SP, Brazil.
Zip Code: 13083-888
[email protected]
144
Acta Paul Enferm. 2013; 26(2):144-9.
Abstract
Objective: To construct a tool for classification of pediatric patients, validate its content, and assess the interrater reliability.
Methods: This is a quantitative study in which a mixed method was used. Validity of its content was assessed
through a descriptive exploratory design using the Delphi technique. Inter-rater reliability was then assessed
with a correlational design.
Results: After four stages of use of the Delphi technique, the instrument was composed of 11 care demand
indicators. Each of them comprised one-to-four situations of graded complexity, that reflected increasing
intensity of nursing need. The reliability levels as optimal, good, and weak were obtained for five, five, and one
indicators, respectively.
Conclusion: The content of the instrument was constructed and validated with satisfactory reliability to classify
pediatric patients into five healthcare categories.
Resumo
Objetivo: Construir, validar o conteúdo e verificar a confiabilidade interavaliadores de um instrumento para a
classificação de pacientes pediátricos.
Métodos: Estudo misto com referencial quantitativo, sendo o delineamento descritivo exploratório para a
validação do conteúdo do instrumento realizado pela Técnica Delphi seguido por desenho correlacional para
avaliar a confiabilidade interavaliadores.
Resultados: Após quatro fases da Técnica Delphi, o instrumento ficou constituído por 11 indicadores de
demanda de cuidado e cada um por quatro situações graduadas refletindo o aumento da necessidade de
enfermagem. Obteve-se nível de confiabilidade ótimo para cinco indicadores; bom para cinco e apenas um
indicador com fraco nível de confiabilidade.
Conclusão: Foi construído e validado o conteúdo do instrumento para classificar pacientes pediátricos em
cinco categorias de cuidados com confiabilidade satisfatória.
Universidade Estadual de Campinas, Campinas, SP, Brazil.
Conflicts of interest: the authors have no conflict to declare.
Dini AP, Guirardello EB
Introduction
Hospitalization in pediatrics is seen as an opportunity for the patients and their caregivers to experience
recovery from illness and expand their knowledge on
health promotion while maintaining the development of the child and preventing new admissions.(1)
In the management of pediatric admission
units, the challenges to ensure high standards of
care safety and quality require that the client profile
be considered since only knowledge of the percent
rate of bed occupancy is not sufficient for the manager to take decisions.(2-4)
Patient Classification Systems (PCS) have been
disseminated since the 1970s as a method to characterize the care profile. In the PCS, the demand for
nursing care by groups of patients is estimated, quantified and evaluated. In addition, the patients are categorized according to the need of care required in a
specific time interval.(3) Furthermore, data obtained
from application of PCS (late 1980s) have been indicated as a basis for planning costs regarding the need
for human and material resources.(4)
Currently, use of PCS contributes to facilitate
communication between nurses and managers, promote professional training by criteria of competence
in giving assistance to different care categories, sustain staff scaling, relocation, and daily allocation of
professionals.(5-8)
The need for tools and concepts of specific categories to classify pediatric patients was identified
in a study (2011) that validated the concept of five
care categories in pediatrics.(9) However, this study
did not indicate a tool to facilitate patient classification in these categories.(9)
Therefore, the aim of this study was to construct
an instrument for classification of pediatric patients
in five care categories, validate its content, and verify its inter-rater reliability.
Methods
This is a mixed study, with a quantitative reference, which was conducted in two sequential steps
[QUAN → quan]. In the first, a descriptive explor-
atory design was utilized to construct the instrument and validate its content. In the second, the
correlational design was utilized to assess the inter-rater reliability of the instrument.
Conceptual references established by the PCS
were taken into account to construct an objective
instrument in the factor assessment style.(3,4)
Four situations increasingly graded (from one to
four points) regarding care requirements were assigned to each indicator.
Validation of instrument content was carried
out by a group of evaluators who used the Delphi
Technique.(10) Three inclusion criteria were utilized
to compose the group of evaluators: to be graduated
in nursing, experienced (for a time equal to or greater
than five years) in pediatric care (or in management
or teaching), and conducting research on construction of instruments for patient classification.
Thus, 19 nurses (time of profession: five-23 years)
participated in the study; six of them were active in
assistance, five in management activity, and eight in
teaching. Regarding professional qualifications, four
nurses had only undergraduate degree, six had professional graduation, and nine had academic graduation
(three of them with master’s and six with PhD degree).
The program using the Delphi technique was obtained by e-mail after the project was submitted and
evaluated for content of the instrument regarding
clarity and relevance of each indicator and its scores.
This technique allows consecutive steps until obtaining at least 70% agreement with instrument content.
Lower levels of consensus required both modification
in the content and a new step of analysis until the level of agreement previously established was reached.(10)
After the final version of the instrument was
obtained, inter-rater reliability was assessed.(11) The
sample consisted of patients admitted to the pediatric unit of a teaching hospital within the State of
São Paulo. Data collection occurred in a single day
after a term of informed consent was signed by the
family. Patients were evaluated with simultaneous
application of the instrument by two nursing graduate students experienced in pediatrics. Data were
analyzed for reliability using the Kappa (k) coefficient as being optimal (k ≥ 0.75), good (0.41 ≤ k ≤
0.74) and weak (k £ 0.40).(11)
Acta Paul Enferm. 2013; 26(2):144-9.
145
Construction and validation of an instrument for classification of pediatric patients
The project of the study met all the national and
international standards of ethics in research involving humans.
Results
At the beginning of construction, the instrument
consisted of ten care indicators, and four steps (us-
ing the Delphi technique) were necessary to validate
the content of all indicators and their respective
scores (Table 1).
After four steps using the Delphi technique,
the instrument has acquired its final configuration
(Table 2).
To assess inter-rater reliability, the instrument
was applied simultaneously in 42 pediatric patients
by two nurses (Table 3).
Table 1. Percent rate of agreement of judges (n=19) with the content of the instrument
Delphi 1
Indicators*
I-1
I-2
I-3
I-4
I-5
I-6
I-7
I-8
I-9
I-10
I-11
I-12
Delphi 2
Delphi 3
Delphi 4
Concepts
Score
Concepts
Score
Score
Score
Relevance
77
46
92
62
57
71
Clarity
62
54
92
69
71
71
Relevance
100
92
92
92
-
-
Clarity
46
85
92
92
-
-
Relevance
100
92
100
100
-
-
Clarity
54
62
100
100
-
-
Relevance
92
77
100
85
-
-
Clarity
85
69
100
100
-
-
Relevance
92
77
100
100
-
-
Clarity
54
69
100
100
-
-
Relevance
92
23
92
54
79
Clarity
46
46
100
85
86
-
Relevance
92
46
100
69
71
-
Clarity
69
69
100
69
86
-
Relevance
100
54
92
46
93
-
Clarity
62
54
92
85
86
-
Relevance
85
77
100
54
57
86
Clarity
62
43
100
69
93
79
Relevance
-
-
100
92
-
-
Clarity
-
-
92
85
-
-
Relevance
-
-
100
77
-
-
Clarity
-
-
92
85
-
-
Relevance
77
46
-
-
-
-
Clarity
62
38
-
-
-
-
Legend: n=19; * I-1: Activity; I-2: Assessment of physiological controls; I-3: Oxygenation; I-4: Drug therapy; I-5: Cutaneous and mucosal integrity; I-6: Feeding and
hydration; I-7: Elimination; I-8: Personal hygiene; I-9: Mobility and ambulation; I-10: Participation of the accompanying person; I-11: Support network; I-12: Education to
the family member
146
Acta Paul Enferm. 2013; 26(2):144-9.
Table 2. Instrument for classification of pediatric patients (ICPP)
Activity: Possibility of maintaining activities compatible with developmental age exercising skills relevant to each age and interacting with
the accompanying person, staff, or other children to make smile, play, talk, etc.
1
Development of activities compatible with the age group
2
Sleepy
3
Hypoactive or hyperactive, or with deficient development
4
Unconscious or sedated, or vigil coma
Physiological controls assessment: need for observation and control of data such as vital signs, central venous pressure, capillary blood
glucose, and water balance.
1
6/6 h
2
4/4 h
3
2/2 h
4
<2h
Oxygenation: ability of the child or adolescent to maintain permeability of airways, and normal ventilation and oxygenation.
1
Spontaneous breathing, without the need for oxygen therapy or airway clearance
2
Spontaneous breathing, with the need for airway clearance by instilling saline
3
Spontaneous breathing, with the need for airway clearance by aspirating secretion and/or need for oxygen
4
Mechanical ventilation (non-invasive or invasive)
Drug therapy: need of the child or adolescent to receive medication
1
No need for medication
2
Need for medication by topical, inhalation, ocular and/or oral route
3
Need for medication by feeding tube or parenteral route (subcutaneous, intramuscular or intravenous)
4
Use of vasoactive agents and/or blood derivatives and/or chemotherapeutic agents
Mucocutaneous integrity: need for maintaining or restoring the mucous and cutaneous integrity
1
Intact skin without change in color across body surface
2
Need for surface bandage, small size
3
Presence of hyperemia (pressure points or perineum) or flogistic signs anywhere in body surface requiring medium size bandage
4
Presence of lesion, with dehiscence or secretion, requirements large size bandage
Feeding and Hydration: the ability of a child or adolescent to ingest food alone, with assistance, by feeding tube, or parenteral route
1
Oral route, independently, or exclusive maternal breastfeeding
2
Oral route, with assistance, and cooperative patient
3
Feeding tube (gastric, enteral, or gastrostomy)
4
Nutrition by parenteral or oral route, patient with difficulty of swallowing, or risk of aspiration
Eliminations: ability of the child or adolescent to perform urinary and intestinal elimination, alone and/or need to use a tube
1
Toilet, without assistance
2
Toilet, with assistance
3
Diaper (need a professional to exchange) or indwelling urinary catheter
4
Intravesical catheter or stoma, or use of bedpan or urinal, or diaper (need two professionals to exchange)
Personal hygiene: ability of the child or adolescent to perform, need assistance, or total dependence for personal hygiene
1
Aspersion bath, without assistance
2
Aspersion bath, with assistance
3
Tub bath or chair bath
4
Bed bath or bath in the incubator, or need more than one nurse to perform any bath
Continued on next page
Acta Paul Enferm. 2013; 26(2):144-9.
147
Construction and validation of an instrument for classification of pediatric patients
Table 2. Continuation
Mobility and ambulation: ability of the child or adolescent to voluntarily move the body or body segments
1
Ambulation without assistance
2
Bed rest, moves without assistance
3
Bed rest, moves with assistance or ambulates with assistance
4
Bedridden, entirely dependent for change in decubitus
Participation of the accompanying person: performance of the accompanying person to perform care and meet the needs of the child or
adolescent
1
The accompanying person recognizes the emotional and physical needs of the pediatric patient and can meet them
2
The accompanying person seeks information to meet the emotional and physical needs of the pediatric patient
3
The accompanying person has difficulty in recognizing some emotional and physical needs of the pediatric patient and resists in seeking help and
making changes
4
The accompanying person appears to be neither attentive nor interested in the emotional and physical needs of the pediatric patient and/or
patient not accompanied
Support Network: support that the child or adolescent can count on during his/her hospital stay
1
Presence of a reliable person accompanying the patient all the time
2
Presence of a reliable person accompanying the patient for more than 12 hours a day
3
Presence of a reliable person accompanying the patient for less than 12 hours a day
4
Not accompanied
Legend: Score to classify patients regarding the level of care: 11-17 points: Minimum care; 18-23 points: Intermediate care; 24-30 points: High-dependency care;
31-37 points: Semi-intensive care; 38-44 points: Intensive care.
Table 3. Kappa (k) values for all indicators of the instrument in the classification of pediatric patients
Levels of reliability
Indicators
Activity
Weak
Good
Optimal
k≤0.40
0.41≤ k≤0.74
k≥0.75
0.38
Physiological controls assessment
0.41
Drug therapy
0.84
Oxygenation
0.86
Cutaneous and mucosal integrity
0.60
Mobility and ambulation
0.66
Personal hygiene
0.67
Feeding and hydration
0.60
Elimination
0.84
Participation of the accompanying person;
0.82
Support network
0.81
Legend: n=42
Discussion
The type of reliability used in this study, not verification of internal consistency of the instrument,
and evaluation of construct validity were the limitations of this study.
This study allowed us to build, validate the
content, and assess the inter-rater reliability of the
148
Acta Paul Enferm. 2013; 26(2):144-9.
ICPP in five care categories defined in the literature as minimal, intermediate, high-dependency,
semi-intensive, and intensive care .(9)
The presence of five care categories was similar
to that in the Fugulin’s instrument (for adult patients in the surgical clinic) but differed from that
in the Perroca’s instrument (for adult patients),
which does not include the high-dependence cat-
egory, and from that in the Bochembuzio’s instrument (for neonatal patients), which includes only
three care categories.(12-14)
The classification of pediatric patients in the
of high-dependence category was considered important because it allows identifying care needs
inherent to the development phase, in which there
is dependence in basic needs, independent of the
clinical stability.(9)
The use of Delphi technique was advantageous
for validation of its content, because it allowed its
assessment by professionals from different geographic locations, hierarchical positions, knowledge, insights, and professional perspectives.(10)
The most important changes in the content of
the instrument occurred in the first stage of the Delphi technique, when the indicator “Education to
the family member” was replaced by “Participation
of the accompanying person” and “Support Network”. In the second stage, all indicators achieved
the consensus established, but the score required
change in six indicators. In the third stage, the score
was validated in four indicators. In the last stage,
the score in the last two indicators reached the level
of agreement established.
We highlight that two indicators related to
family members were validated, since their presence in the hospital environment has determined
changes in the care and challenged the staff in a
new perspective of care quality, which includes
provision of care, involvement of accompanying
persons in daily actions, and promoting continuity of the treatment at the patient’s home.(1,2)
In the assessment of inter-rater reliability,
ICPP showed optimal reliability levels for five indicators; good for five indicators, and weak for
only one indicator.(11)
Conclusion
The content of the instrument for classification of
pediatric patients was constructed and validated in
five care categories with a satisfactory reliability.
Collaborations
Dini AP and Guirardello EB declare that they contributed equally to the conception and design of
the study, analysis and interpretation of data, writing of the manuscript, critical review for relevant
intellectual content, and final approval of the version to be published.
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4. De Groot HA. Patient classification system evaluation. Part 1: Essential
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6. Perroca MG, EK AC. Utilization of patient classification systems in
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Acta Paul Enferm. 2013; 26(2):144-9.
149
Artigo Original
Prevalence of drug interactions in
intensive care units in Brazil
Prevalência de interações medicamentosas em
unidades de terapia intensiva no Brasil
Rhanna Emanuela Fontenele Lima de Carvalho1
Adriano Max Moreira Reis2
Leila Márcia Pereira de Faria1
Karine Santana de Azevedo Zago3
Silvia Helena De Bortoli Cassiani1
Keywords
Nursing; Nursing practice; Nursing care;
Drug interactions; Intensive care units
Descritores
Enfermagem; Enfermagem prática;
Cuidados de enfermagem; Interações
de medicamentos; Unidades de terapia
intensiva
Submitted
March 28, 2012
Accepted
February 21, 2013
Adriano Max Moreira Reis
Antônio Carlos Avenue, 6627,
Pampulha, Belo Horizonte, MG, Brazil.
Zip Code: 31270-901
[email protected]
150
Acta Paul Enferm. 2013; 26(2):150-7.
Abstract
Objective: To determine the prevalence of drug interactions in intensive care units and to analyze the clinical
significance of interactions identified.
Methods: A multicenter, retrospective and cross sectional study conducted with 1124 patients in the seven
intensive care units of teaching hospitals in Brazil. Information on drugs administered at 24 hours and 120
hours of hospitalization was obtained from the prescriptions.
Results: Within 24 hours, 70.6% of patients had at least one drug interaction; the number at 24h was 2299,
at 120 h it was 2619. Midazolam, fentanyl, phenytoin and omeprazole were the drugs with higher frequency
of drug interactions.
Conclusion: In this sample, moderate and severe drug interactions were more prevalent. In light of these
findings, all actions of health professionals who provide care to these patients must be integrated in order to
identify and prevent possible drug events.
Resumo
Objetivo: Determinar a prevalência de interações medicamentosas em Unidades de Terapia Intensiva-UTI
brasileiras e analisar seu significado clínico.
Métodos: Estudo multicêntrico, retrospectivo, desenvolvido com 1.124 prontuários em sete UTI de hospitais
de ensino brasileiros. As informações sobre os medicamentos prescritos e administrados em pacientes com
24 horas e 120 horas de internação foram obtidas baseadas nas prescrições.
Resultados: Em 24 horas, 70,6% dos pacientes de UTI tinham, pelo menos uma interação medicamentosa.
O número total de interações detectadas foi de 2.299 em 24 horas, e 2.619 em 120 horas. Midazolam,
Fentanyl, Phenytoin e Omeprazole foram os medicamentos que apresentaram maior frequência de interação
medicamentosa.
Conclusão: Na amostra estudada, as interações medicamentosas graves e moderadas foram mais prevalentes.
Neste sentido, todas as ações dos profissionais de saúde que prestam cuidados a esses pacientes devem ser
integradas no intuito de identificar e prevenir possíveis eventos com medicamentos.
Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.
3
Universidade Federal de Uberlândia, Uberlândia , MG, Brazil.
Conflicts of interest: the authors declare that they have no potential conflicts of interest.
1
2
Carvalho REFL, Reis AMM, Faria LMP, Zago KSA, Cassiani SHB
Introduction
The patients from intensive care units (ICUs) have
a higher risk of developing drug interactions (DI)
than patients from other care units. In addition to
the risk attributed to multiple drugs, there is risk
resulting from the severity of the illnesses and organ
failure. Studies have shown a positive correlation
between the many different drugs and DI. Drug
interactions contribute to the incidence of adverse
reactions in ICU and often constitute an unrecognized complication in pharmacotherapy. The DI
may be beneficial or harmful, depending on various factors related to the medication, the patient or
the conditions under which the medication is used.
(1)
Beneficial or desirable interactions aim to treat
diseases, reduce adverse effects, increase efficiency
or allow the reduction of the dose. On the other
hand, the harmful interactions are those that cause
a reduction of the effect or results contrary to those
expected, or that increase incidence and profile of
adverse reactions and the cost of therapy, without
an increase in therapeutic benefit.(2)
The prevalence of potential drug interactions in
the ICU detected in observational studies ranged
from 44.3% to 86%.(3-4) In the literature researched,
the prevalence of drug-enteral nutrition interactions
in intensive care was not identified.
Beyond the risk attributed to multiple drugs, patients in the ICU presented a risk due to the severity
of illness and organ failure. Changes in the volume of
drug distribution and other pharmacokinetic factors
also contribute to a decrease in the safety of medicines in these patients. The activity of cytochrome
P450 and the effect of P-glycoprotein are important
determinants of the pharmacokinetic processes of
a significant number of drugs, and are involved in
the mechanisms of clinically important interactions
in ICU.(2) In addition to the risk of drug-drug interactions, patients in ICUs have higher predisposition to drug-nutrient interactions. Due to their
severe clinical status, these patients receive nutrition
through nasoenteric feeding tubes, nasogastric tubes
or stoma. However, these devices are not only used
for the administering of food, but often are also used
for the delivery of medication. The consequence of
this practice is the risk of adverse events such as the
obstruction of the tube, physicochemical incompatibilities and drug-nutrient interactions.(5)
Health professionals’ knowledge about DI and
their clinical significance, especially those responsible for prescriptions, could help predict DI and
minimize the negative impacts through adequate
monitoring, when the combination is unavoidable.
This kind of attitude of the health care team contributes to the optimization and safety of pharmacotherapy in critically ill patients.
Therefore, the objectives of this study were to
determine the prevalence of drug interaction in the
ICUs of seven hospitals in Brazil, and to analyze the
clinical significance of the interactions identified.
Methods
This was a multicenter, retrospective and cross sectional study conducted in the ICUs of seven teaching
hospitals in Brazil. The hospitals were located in the
west central, northeast and southeast regions of Brazil, all belonging to the Sentinel Network of Hospitals of the National Health Surveillance Agency.
The medical records of patients in 2007, hospitalized in the ICUs of the hospitals studied, were
included in the research. The demographic information and main diagnosis were extracted from
the patients’ clinical history records. Information
regarding medications and enteral nutrition administered at each of the two time points were collected
from the medical prescription documentation.
The sample selection was random, with patients
who met the following criteria participating in the
study: over 18 years of age, and a length of stay in
the ICU for a period of no less than 120 hours. Patients younger than 18 years or with length of stay
less than five days, was excluded the study.
We constructed a specific instrument to assist in
data collection. Using this data collection instrument,
information was collected from patients, including:
age, gender, length of hospitalization, primary diagnoses (according to the International Statistical Classification of Diseases and Related Health Problems ICD 10), and information about drugs administered
Acta Paul Enferm. 2013; 26(2):150-7.
151
at 24 hours and 120 hours of hospitalization. These
time intervals were chosen because of the quantity of
drugs prescribed on the first day of hospitalization in
the ICU, and after the first week of hospitalization the period of greatest therapeutic adjustment.(3)
Potential DI are interactions that could theoretically occur during the patient’s pharmacotherapy
treatment, and which may or may not be clinically
manifested. In the present investigation the terminology “drug interaction” will be used to refer to
the area that includes drug-drug interaction and
drug-enteral nutrition interaction.
For the identification of potential drug-drug interactions and drug-enteral nutrition interactions,
the Drug Reax® software was used, developed by
Thomson Micromedex TM, Greenwood Village, CO,
USA.(6) This software has the adequate sensitivity to
detect drug interactions in the hospital.(7) The Drug
Reax software provides information on clinical outcomes or adverse drug reactions resulting from the
interaction, and characterizes the mechanism of action. It classifies the interactions in relation to severity in five categories (contraindication, severe, moderate, mild and unknown), onset (early and late), and
level of scientific evidence (excellent, good, fair, poor,
unknown and unlikely).(6) The mechanism of action
of the interaction was classified as pharmacokinetic,
pharmacodynamic or mixed. For the pharmacokinetic interactions the process involved was identified
(absorption, distribution, metabolism or excretion).
The data was stored in Microsoft® Access 2007. For
statistical analysis, StatSoft® version 8.0 was used.
Descriptive analysis was performed using frequency distribution for the categorical variables,
and the central tendency measures (mean) and
dispersion (standard deviation) were used for the
quantitative variables.
The study followed the development of national
Results
The study included 1124 patient records, 630
(56%) of which were from male patients. The
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Acta Paul Enferm. 2013; 26(2):150-7.
mean age was 52.5 years (± 19.0), with a minimum age of 18 and a maximum of 96.8 years. The
mean length of stay was 19.4 days (± 23.0). The
most common diagnoses for both 120 hours and
24 hours were: circulatory diseases, respiratory
diseases, injuries caused by poisoning, and certain
other consequences of external causes. The number of drugs prescribed per patient in a 24 and
120-hour period was equivalent to 13.6 (± 45) and
13.2 (± 4.8), respectively.
The prevalence of potential DI at 24 and 120
hours of hospitalization is presented in table 1. In
the first 24 hours, 70.6% of the patients had at least
one DI. The total number of DI was 2299, with
350 types of drug-drug interactions and three types
of drug-enteral nutrition interactions. The prevalence of interactions at 120 hours was 72.5%. The
number of DI detected at 120 hours was higher, at
2619, with 419 types of drug-drug interactions and
four drug-enteral nutrition interactions. The average number of DI per patient increased from 2.9
(24 hours) to 3.3 (120 hours).
An enteral feeding was received by 320 (28.5%)
patients with 24 hours of admission, and 504
(44.8%) with 120 hours. The prevalence of drug-enTable 1. Prevalence of potential drug interactions in seven
intensive care units
Variable
n
24 hours of hospitalization
Number of patients with drug interactions
793(70.6)
Total drug interactions
2299
Types of drug interactions
353
Drug-drug interactions
350
Drug-enteral nutrition interactions
Number of drug interactions per
patient - mean (min, max)
3
2.92(1.18)
120 hours of hospitalization
Number of patients with drug
interactions
815 (72.5)
Total drug interactions
2619
Types of drug interactions
423
Drug-drug Interactions
419
Drug-enteral nutrition interactions
Number of drug interactions per
patient - mean (min, max)
4
3.3 (1.18)
teral nutrition interaction among these patients was
found to be 20 (6.3%) and 39 (7.7%), respectively.
Table 2 presents the characteristics of potential
interactions with respect to severity, time of onset,
mechanism of action, and the level of scientific evidence. The severe and moderate potential interactions, together, accounted for 86% of the interactions, at both periods investigated. The frequency
of potentially serious interactions was 36.5% (24
hours) and 35.2% (120 hours), respectively. The
level of evidence for approximately 60% of the interactions was good. There is a balance in relation
to the mechanism of action of potential interactions in 24 hours, with 982 (42.7%) of the pharmacokinetic type and 946 (41.1%) of the pharmacodynamic type. At 120 hours there was already a
Table 2. Classification of potential drug interactions identified
in seven intensive care units
Prescription
Classification
24 hours
120 hours
n(%)
n(%)
slight predominance of potential interactions with
a pharmacodynamic mechanism of action, with a
frequency of 1104 (42.2%). The potential interactions of pharmacokinetic mechanisms totaled
1037 (39.6%). Analyzing the distribution of cases of potential pharmacokinetic drug-drug interactions, the metabolism process was identified as
being responsible for 88.5% of the potential interactions at 24 hours, and 83.1% at 120 hours.
The number of the processes was different because
a pharmacokinetic interaction can be determined
by more than one process.
The most frequent serious potential interactions
at 24 and 120 hours, with absolute frequency greater than 10, are listed in table 3.
The potential interactions of moderate severity
most prevalent at 24 hours were midazolam +omeTable 3. Most frequent serious drug interactions in seven
intensive care units
Prescription
Drug-drug interaction
Severity
Contraindicated
2(0.1)
5(0.2)
Fentanyl + Midazolam
24 hours
120 hours
n(%)
n(%)
324(38.6)
215(23.3)
Major
840(36.5)
922(35,2)
Captopril + Potassium Chloride
54(6.4)
97(10.5)
Moderate
1151(50.1)
1347(51.4)
Salicylic Acid + Heparin
47(5.6)
80(8.7)
Minor
306(13.3)
345(13.2)
Clopidogrel + Enoxaparin Sodium
21(2.5)
15(1.6)
Amiodarone + Fentanyl
18(2.1)
28(3.0)
Excellent
242(10.5)
342(13.1)
1468(63.9)
1548(59.1)
Fentanyl + Nimodipine
19(2.3)
14(1.5)
Good
Fair
589(25.6)
727(27.8)
Clopidogrel + Omeprazole
16(1.9)
18(2.0)
0(0)
2(0.1)
Fentanyl + Fluconazole
16(1.9)
20(2.2)
Haloperidol + Tramadol
16(1.9)
19(2.1)
982(42.7)
1037(39.6)
Fentanyl + Phenobarbital
15(1.8)
-(-)
946(41.1)
29(1.3)
342(14.9)
1104(42.2)
42(1.6)
436(16.6)
Fentanyl + Nifedipine
14(1.7)
18(2.0)
Clopidogrel + Heparin
14(1.7)
17(1.8)
Ciprofloxacina + Insulin
14(1.7)
22(2.4)
65(6.4)
3(0.3)
895(88.5)
94(8.7)
5(0.5)
900(83.1)
Midazolam + Phenobarbital
13(1.5)
-(-)
Midazolam + Morphine
11(1.3)
-(-)
49(4.8)
84(7.7)
Captopril + Spironolactone
0(0)
17(1.8)
Clonidine + Propranolol
0(0)
13(1.4)
Immediate
585(49.7)
841(32.1)
12(1.3)
12(1.3)
Late
Unknown
1142(25.4)
1292(49.3)
Others
216(25.8)
317(34.4)
572(24.9)
486(18.6)
Total
840(100.0)
922(100.0)
Documentation
Unknown
Mechanism of action
Pharmacokinetic
Pharmacodynamic
Mixed
Unknown
Pharmacokinetic process
Absorption
Distribution
Metabolism
Excretion
Onset
Insulin +Levofloxacin
Acta Paul Enferm. 2013; 26(2):150-7.
153
prazol and fentanyl + phenytoin in this category,
while at 120 hours it was midazolam + omeprazole
and omeprazole + phenytoin.
Discussion
The identification of interactions using a retrospective software approach detects potential interactions, which does not mean that the possible
adverse events manifested clinically in all patients
with those potential drug-drug or drug-enteral
nutrition interactions.
The software is an important tool to verify
potential DI, but it generally produces a high signal level that may indicate a higher prevalence of
potential interactions.(8) Therefore, it is important to consider the magnitude of the interaction
in the clinical area of ICU, in terms of severity
and associated adverse events, in addition to the
overall prevalence.
The frequency of potential interactions detected
at 24 hours and 120 hours of patient exposure was
approximately 70% (Table 1). The prevalence in
the sample studied was lower than in other national
studies, where the prevalence was over 85%.(4,9) In
the design of this study, which evaluated medication prescriptions at two periods of hospitalization,
variations in the complexity of ICU care, as well as
differences in the level of sensitivity and specificity
of the methodologies used in identifying the potential interactions may explain the discrepancy and
minimize the value of comparisons between different studies. The average number of drugs prescribed
per patient is one of the determinants of percentage
of interactions.
Another distinguishing feature of the present
study, which also may explain the lower prevalence, is
the employment of a selective criterion for potential
interactions with aspirin. Potential interactions were
excluded that, according to the Drug Reax software,
occured at doses above 300 mg. This criterion was
used because in the pilot study it was verified that
these doses were not frequent in the ICUs investigated. Aspirin is usually used in doses of 100mg with an
objective that is therapeutically anti-platelet.
154
Acta Paul Enferm. 2013; 26(2):150-7.
The impact of the prevalence of DI in healthcare settings gains greater importance when coupled with information identifying its clinical significance. The clinical significance is determined
by severity, level of evidence and clinical consequences.(6) Potential interactions detected in the
two time periods studied were predominantly
moderate and severe (Table 2).
The most frequent interaction, at 24 hours and
120 hours, was midazolam + fentanyl. This pharmacodynamic interaction is an example of an interaction that is used therapeutically. The efficacy of
the combination of midazolam + fentanyl sedation
in mechanically ventilated patients was compared
with the use of midazolam in a randomized, unblinded clinical trial. The researchers found that
joint administration by continuous infusion provided more adequate sedation and ease of dose titration than with midazolam alone, with no difference
in the rate of adverse occurrences.(10) However, it is
important to note that in the midazolam + fentanyl
group, adverse events were detected: hypotension
and hypoventilation, which justifies the classification of this interaction as severe.
To combine therapeutic goals and patient safety,
one important strategy for monitoring sedation is the
use of appropriate scales such as the Ramsay Sedation
Scale, and the development of protocols for sedation.
The nursing role is important in the monitoring of
patients to ensure safe and effective sedation.(10)
Potential
pharmacodynamic
interactions
showed a significant prevalence in the study and
demonstrated characteristics of causing clinically
significant adverse events in the respiratory and cardiovascular systems: midazolam + morphine, fentanyl + morphine, fentanyl + phenobarbital.
Fentanyl + nimodipine and fentanyl + nifedipine were other potentially serious interactions, because of the risk of hypotension. At 120 hours of
hospitalization fluconazole + fentanyl was the most
frequent interaction. This antimicrobial is an inhibitor of CYP4503A4, increasing blood levels of
fentanyl and the risks of sedation and its adverse
effects. In this case, the adherence to sedation protocols is also an appropriate strategy in identifying
and monitoring the effects of the interaction.
The omeprazole + midazolam pharmacokinetic interaction was the most prevalent in the study.
Moderate in severity, the mechanism of this interaction is to reduce the metabolism of midazolam by
omeprazole, an inhibitor of cytochrome P4503A4.
The scientific evidence is reasonable, because studies that demonstrated this interaction were in vitro.
However, considering the context of the ICU it is
important to monitor the level of sedation and, if
necessary, to adjust the dose of medication in patients on concomitant use of these drugs.(6)
Phenytoin is a drug of narrow therapeutic index and a potent enzyme inducer, with pharmacological characteristics which are predisposed to
potential DI, with significant clinical consequences. The determination of plasma levels is a suitable
tool for monitoring the evolution of the successful management and interaction with dose adjustment.(2) The diversity of potential interactions
with phenytoin, together with their pharmacotherapy characteristics, are aspects which suggest
that nurses and other health team members should
consider the likelihood of potential interactions
with this drug in patients undergoing multiple
drug therapy.
Interactions with omeprazole, nifedipine or
amiodarone are examples in which the drug phenytoin is the object of interaction. The consequence
is the increased plasma levels of phenytoin, the clinical manifestations of which are ataxia, nystagmus,
shivering and hyperreflexia.(6)
On the other hand phenytoin can be a precipitating agent of the interaction, reducing the plasma
levels of any other drug that participates in the interaction. The reduction in plasma levels occurs due
to the inducing activity of phenytoin, and helps to
decrease the effectiveness of the drug that is under
the effect of enzyme induction, which may lead to
therapeutic failure.(6)
A serious frequent interaction in the two periods of hospitalization was that of captopril + potassium chloride, which could result in hyperkalemia
with serious clinical consequences, especially in the
elderly, and patients with heart failure or renal insufficiency. Hyperkalemia can also arise from other
potential interactions detected in this study, such as
spironolactone + captoptril, and spironolactone +
potassium chloride.(6)
Potential interactions of clinical significance occur with amiodarone because of its inhibiting activity of P-glycoprotein and CYP4503A4. Amiodarone
is used to treat supraventricular arrhythmias such
as atrial fibrillation, which constitutes the most
frequent arrhythmia in ICU.(2,6) This therapeutic
measure explains the widespread use of this drug
in the ICU, and the frequency of potential interactions with amiodarone detected in this study. Given
the risk of potential interactions, it is important to
identify and monitor them to achieve the expected
results and ensure the safety of the therapy.
Thus, the joint treatment of amiodarone + fentanyl requires close monitoring because of the risk
of cardiotoxicity and the increased toxic effects arising from the interaction of fentanyl pharmacokinetics. Simultaneous use with nifedipine and other
drugs that increase atrioventricular block may exacerbate bradycardia and signs of heart blockage.
Use of amiodarone + simvastatin increases the risk
of myopathy or rhabdomyolysis because of the increased plasma concentration of simvastatin, due to
the inhibition of its metabolism by amiodarone. The
inhibition of the P-glycoprotein by amiodarone implies reduced digoxin clearance, increasing the plasma level and the chances of digitalis intoxication.
Dose reduction and periodic monitoring of plasma
digoxin is essential to minimize the effects of this
interaction. These potential interactions were more
frequent with amiodarone in this study.(2,6)
There is an increasing concern with drugs that
have the property of prolonging the QT interval,
because of the risk of cardiotoxicity with torsade de
points and cardiac arrest.(11) These adverse events
may be determined by potential pharmacokinetic
interactions that inhibit the metabolism of drugs
with this property or pharmacodynamic synergism.
The potential interactions between amidorane +
metronidazole, fluconazole + sulfamethoxazole / trimethoprim, fluconazole + haloperidol, haloperidol
+ amiodarone detected in this study may produce
the adverse events cited. Thus, the health care team
must be knowledgeable of the drugs that prolong
the QT interval, as well as other risk factors that
Acta Paul Enferm. 2013; 26(2):150-7.
155
contribute to this phenomenon, in order to adopt
appropriate strategies to manage and monitor the
effects of potential interactions.
Recently, observational studies have identified
negative results in patients using the clopidrogrel
+ omeprazole interaction after their discharge from
hospitalization for acute coronary syndrome. The
main negative outcomes evaluated were death and
hospital readmissions for myocardial infarction
or unstable angina. A retrospective cohort study
demonstrated an association between the risk of
adverse outcomes and the concomitant use of omeprazole + clopidrogrel in patients after hospitalization for acute coronary syndrome.(12) Equivalent results were found in a Canadian study with patients
hospitalized for acute myocardial infarction.(13)
These studies confirmed hypotheses generated from
experimental studies that showed that omeprazole
acts on cytochrome P4502C19, inhibiting the bioactivation of the prodrug clopidogrel to its active
form, reducing its antithrombotic effect.
In the context of the ICU, it is important to investigate both the potential drug-drug interactions
as well as potential drug-enteral nutrition interactions. In the sample researched the incidence was
low, but it is noteworthy that the potential drug-enteral nutrition interactions have clinical impact,
and may interfere with the results of the pharmacotherapeutic plan developed for the patient. In the
literature studied, no studies were found evaluating
this type of interaction in the ICU. Among the interaction analysis software that exists, the detection
of potential drug-enteral nutrition interactions is a
peculiarity of Drug Reax.
Potential drug-enteral nutrition interactions
identified in the study involved four drugs: hydralazine and three with a narrow therapeutic index
(phenytoin, warfarin, and levothyroxine), which
points to the clinical importance of these potential
interactions. The investigations regarding the potential drug-enteral nutrition interactions are insufficient, and few in number.(14,15)
The mechanisms of potential drug-nutrient interactions involve physical and chemical reactions
of drugs with dietary components that lead to a
reduction of bioavailability. Another factor that
156
Acta Paul Enferm. 2013; 26(2):150-7.
contributes to reducing the plasma concentration
of drugs is absorption in the walls of the enteral
feeding tubes.(15)
A strategy identified to reduce the effects of
potential drug-enteral nutrition interactions is
planning the schedule of drug administration with
consideration of the frequency and type of enteral
nutrition administration. This aspect is more easily
handled when the drug is administered in a single
dose while nutrition is administered via bolus or
intermittently. A complexity arises with multiple
schemes of drug administration and continuous
nutritonal infusion, since discontinuation of the
feeding is required to administer medication, thereafter adjusting for dietary administration to ensure
the prescribed caloric intake.(15) Normally, it is recommended to stop the feedings one to two hours
before and after the administration of drugs.(14,15)
The role of the nurse, together with the physician, pharmacist and nutritionist, includes an
outlining of the timetable, and care in the administration of these drugs to avoid drug-enteral
nutrition interaction.
Potential interactions involving absorption
were limited in this study, with greater frequency
at 120 hours when the patient was clinically stable
and had less need for using the parenteral route.
The potential interactions identified in the study
that involved reactions that reduced absorption
were: levothyroxine + sevelamer, ketoconazole +
ranitidine, omeprazole + atazanavir, and, calcium
carbonate + captopril.
This multicenter study contributed significantly
to the practice of critical care nursing by presenting
the profile of DI in the ICU within Brazil, building
an important tool for planning and interventions
for improving patient safety in ICU. To increase
the safety of patients, it is essential to implement
strategies that help the healthcare team to identify
potential interactions and implement prevention
and monitoring of patients at risk of developing DI,
before they manifest.
The nurse, as the individual responsible for the
scheduling of the drugs and enteral nutrition, is
key to the prevention of potential drug-enteral nutrition interactions and potential interactions in-
volving the absorption process, contributing to the
pharmacotherapy effectiveness for patients.(16)
However, planning the schedule has little impact in the prevention of potential pharmacokinetic
interactions that involve either the metabolism process or pharmacodynamics. For these categories, the
main preventative measures are related to strategies
such as: avoiding using them together, adjusting the
dose of the drug object of interaction and clinical
monitoring for early detection of adverse effects.
The performance of the nurse can contribute to
patient safety and prevent unwanted DI. However,
the impact of actions will be most effective if developed in an interdisciplinary manner.
Conclusion
In this sample, the moderate and severe DI were
more prevalent, in virtue of the profile of the patients and the complexity of the pharmacotherapy,
requiring the integrated execution of the health
team to better identify and prevent their occurrence.
Knowledge of the pharmacological mechanisms
and the main risk factors of drug-drug interactions
and drug-enteral nutrition interactions contributes to
adequate programs in helping to prevent them, enables
the optimization of the drug therapy and, as a result,
increases the safety and effectiveness of the treatment.
Acknowledgments
Supported by Fundação de Amparo à Pesquisa de
São Paulo – FAPESP (nº2006/05882-8) – São Paulo, SP, Brazil.
Collaborations
Carvalho REFL; Reis AMM; Faria LMP; Zago KSA
and Cassiani SHB contributed to study conception,
analysis and interpretation, the literature review, research design, interpretation of data, data collection,
input, analysis and interpretation, drafting of manuscript and final approval of submitted manuscript.
References
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LL. Preventable adverse drug events in hospitalized patients: a
comparative study of intensive care and general care units. Crit Care
Med. 1997;25(8):1289-97.
2. Spriet I, Meersseman W, de Hoon J, von Winckelmann S, Wilmer A,
Willems L. Mini-series: II. Clinical aspects. Clinically relevant CYP450mediated drug interactions in the ICU. Intensive Care Med. 2009;
35(4):603-12.
3. Lima RE, De Bortoli, Cassiani SH. Potential drug interactions in
intensive care patients at a teaching hospital. Rev Latinoam Enferm.
2009;17(2):222-7.
4. Hammes JA, Pfuetzenreiter F, Silveira F, Koenig A, Westphal GA.
Potential drug interactions prevalence in intensive care units. Rev Bras
Ter Intensiva. 2008;20(4):349-54.
5. Heineck I, Bueno D, Heydrich J. Study on the use of drugs in patients
with enteral feeding tubes. Pharm World Sci. 2009;31(2):145-8.
6. Drug-Reax® System [Internet]. Greenwood Village (CO): Thomson
Reuters; 2008. [cited 2008 Nov 16]. Available from: https:/ /www.
thomsonhc.com.
7. Vonbach P, Dubied A, Krähenbühl S, Beer JH. Evaluation of frequently
used drug interaction screening programs. Pharm World Sci.
2008;30(3):367-74.
8. Egger SS, Drewe J, Schlienger RG. Potential drug-drug interactions
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Pharmacol. 2003;58(11):773-8.
9. Menezes A, Monteiro HS. [Prevelance of potential “drug-drug”
medication interactions in two ICUs (public & private) in Foraleza,
Brazil]. Rev Bras Ter Intensiva. 2000; 12(1):4-7. (Portuguese)
10. Richman PS, Baram D, Varela M, Glass PS. Sedation during mechanical
ventilation: a trial of benzodiazepine and opiate in combination. Crit
Care Med. 2006;34(5):1395-401.
11.Letsas KP, Efremidis M, Kounas SP, Pappas LK, Gavrielatos G,
Alexanian IP, et al. Clinical characteristics of patients with drug-induced
QT interval prolongation and torsade de pointes: identification of risk
factors. Clin Res Cardiol. 2009;98(4):208-12.
12. Ho PM, Maddox TM, Wang L, Fihn SD, Jesse RL, Peterson ED, et al. Risk
of adverse outcomes associated with concomitant use of clopidogrel
and proton pump inhibitors following acute coronary syndrome. JAMA.
2009;301(9):937-44.
13.Juurlink DN, Gomes T, Ko DT, Szmitko PE, Austin PC, Tu JV, et al. A
population-based study of the drug interaction between proton pump
inhibitors and clopidogrel. CMAJ. 2009;180(7):713-8.
14.Williams TA, Leslie GD. A review of the nursing care of enteral
feeding tubes in critically ill adults: part II. Intensive Crit Care Nurs.
2005;21(1):5-15.
15. Williams NT. Medication administration through enteral feeding tubes.
Am J Health Syst Pharm. 2008; 65(24):2347-57.
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Acta Paul Enferm. 2013; 26(2):150-7.
157
Original Article
Vertical transmission of HIV in the
population treated at a reference center
Transmissão vertical do HIV em população atendida no serviço de referência
Sueli Teresinha Cruz Rodrigues1
Maria José Rodrigues Vaz2
Sonia Maria Oliveira Barros3
Keywords
Obstetric nursing; Nursing care;
Acquired immunodeficiency syndrome;
HIV infeccions
Descritores
Enfermagem obstétrica; Cuidados
de enfermagem; Síndrome da
imunodeficiência adquirida; Infecções
por HIV
Submitted
April 2, 2012
Accepted
February 21, 2013
Sueli Teresinha Cruz Rodrigues
Lorival Melo Mota Avenue, S/N, BR 101,
North Km 97, Campus A. C. Simões,
Tabuleiro dos Martins, Maceió, AL,
[email protected]
158
Acta Paul Enferm. 2013; 26(2):158-64.
Abstract
Objective: To identify the rate of vertical transmission of HIV and assess the factors involved in maternal and
fetal share.
Methods: Cross-sectional study conducted in the Specialized Care Service. We investigated 102 clinical records
of HIV positive women who had given birth to live newborns. The primary variable was the occurrence of vertical
transmission of HIV and the secondary variables were the factors associated with vertical transmission of HIV.
Results: Prevalence of 6.6% of vertical transmission. Among the infected children: 40.0% of mothers with out
prenatal care and 75% without prophylaxis with antiretroviral drugs during the prenatal, 50.0% without AZT
prophylaxis with oral and breast-fed. Among the uninfected children: 91.5% were started on prophylaxis with
oral AZT at birth and 84.1% of mothers received ARV delivery.
Conclusion: The occurrence of vertical transmission of HIV in the reference service corresponded to 6.6%,
indicating a high prevalence.
Resumo
Objetivo: Identificar a taxa de transmissão vertical do HIV e avaliar os fatores envolvidos em partes
materna fetal.
Métodos: Estudo transversal realizado no Serviço de Atendimento Especializado. Foram investigados 102
prontuários de mulheres com HIV que deram à luz a recém-nascidos vivos.
Resultados: A prevalência de 6,6% de transmissão vertical. Entre as crianças infectadas: 40,0% de mães
sem pré-natal e 75% sem a profilaxia com anti-retrovirais durante o pré-natal, 50,0% sem profilaxia com
AZT com oral e amamentado. Entre as crianças não infectadas: 91,5% iniciaram a profilaxia com AZT oral ao
nascimento e 84,1% das mães receberam ARV.
Conclusão: A ocorrência de transmissão vertical do HIV no serviço de referência correspondeu a 6,6%, o que
indica uma alta prevalência.
Universidade Federal de Alagoas, Maceió, AL, Brazil.
Hospital Universitário, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
3
Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
Conflict of interest: Barros SMO is currently the editor in chief of Acta Paulista Enferm. This paper was
submitted and evaluated before assuming this role.
1
2
Rodrigues STC, Vaz MJR, Barros SMO
Introduction
The pandemic of human immunodeficiency virus
(HIV) represents one of the most serious health
crises in the world; there are 34 million people infected worldwide, including more than 15.4 million women. In Brazil in 2009, there were 38,538
reported cases of the disease with an incidence rate
of 20.1 cases per 100,000 inhabitants. The prevalent form of transmission among those older than
13 years old is sexual, and this principal subcategory
of exposure is growing.(1,2)
The HIV / AIDS epidemic in Brazil is associated with the trend toward the feminization of
poverty; the incidence rates in recent years have
affected mainly women with lower education.
National trends show that in the south, southeast and west-central regions of Brazil, the feminization of the epidemic is stabilizing, but in the
north and northeast the trend shows growth.The
prevalence among women in Brazil, between 15
and 49 years, is 0.6%; among pregnant women it
is 0.41%.(3,4)
The growth of AIDS cases among women has, as
a consequence, the increase in vertical transmission
of HIV infection. Almost all AIDS cases in children
under 13 years of age have vertical transmission of
HIV as their source of infection.(8) The rate of vertical transmission of HIV, without any intervention,
stands at around 25.5%, and it is possible to reduce
this to levels between zero and 2%, by means of preventive interventions. However, only a broad implementation of these interventions will result in a
significant reduction in the incidence of AIDS cases
in children.(5-9)
This study arose from the observation of rapid and significant epidemiological transformations
that this pandemic has undergone over the years,
and with the professional in the team interacting
with the SAE, and the direct involvement with the
nursing care for pregnant women with HIV at the
referral center in the city, since 2004.
The evolution of the AIDS epidemic in Brazil, in a manner especially affecting women, has
brought the control of vertical transmission of
HIV as a new challenge to be faced, and so it has
become a relevant and compelling objective to
identify the rate of vertical transmission of HIV
at the referral center in the city of Maceió, Alagoas, and to assess the associated maternal and
fetal risk factors.
Methods
This was a cross-sectional study conducted in the
Specialized Care Service (SCS)-PAM Salgadinho,
in the unit linked to the Municipality of Maceió,
Alagoas State, northeast of Brazil.
We investigated clinical records of HIV positive women who had given birth to live newborns.
We included women diagnosed with AIDS or HIV
with positive serology confirmed prior to pregnancy, during prenatal care or on the maternity unit; all
children born of these women were included in the
study, with positive or negative diagnosis of HIV
transmission, during the period from January 2002
to December 2006.
The primary variable was the occurrence of
vertical transmission of HIV and the secondary
variables were the factors associated with vertical transmission of HIV. The terms of the factors
associated with vertical transmission for this research were modeled from the Record of Inquiry
and Notice of HIV positive pregnant women and
children exposed.
The determination of sample size considered the
number of visits made during

the study period. The
sample size was 102 records (mother-child) and of
these, 76 charts were evaluated that met the inclusion criteria of the study.
Qualitative variables were presented as absolute
frequencies (n) and relative frequencies (%). Quantitative variables of the mean, median and standard
deviation were calculated, along with minimums
and maximums, to identify variation. An analysis
for tests of comparison of qualitative variables utilized the Fisher’s exact test, and we considered the
level of significance to be 5%.
The study followed the development of national
Acta Paul Enferm. 2013; 26(2):158-64.
159
Table 2. Distribution of prenatal care according to infected and
uninfected children
Results
The sociodemographic characteristics of the 76
women studied are presented in table 1. It can be
observed that the majority were young, of childbearing age, and that low levels of education were
significant in this population.
Non infected
Infected
n(%)
n(%)
Maternal
age (in
complete
years)
Between 15 and 19 years
14(20.0)
0(0)
54(77.1)
4(100.0)
2(2.9)
0(0)
Years
of study
(Education)
None
15(29.4)
1(33.3)
7(13.7)
1(33.3)
24(47.1)
0(0)
5(9.8)
1(33.3)
Municipality
of residence
Rural zone of Alagoas
2(2.9)
0(0)
Urban/rural area of Alagoas
16(22.9)
1(33.3)
Maceió
52(74.3)
2(66.7)
Sexual
partner
Serology status unknown
11(23.9)
0(0)
Multiple partners
4(8.7)
1(25.0)
Uninfected partner
6(13.0)
0(0)
Infected partner
25(54.3)
3(75.0)
There was a statistically significant association
related to vertical transmission, for these variables:
the city in which prenatal care was obtained, whether or not prenatal care was obtained, and the use of
antiretrovirals during prenatal care (Table 2).
The recommended care in Maceió for the mother at delivery, which are protective factors for vertical transmission and that resulted in the highest
160
Acta Paul Enferm. 2013; 26(2):158-64.
Infected
n(%)
n(%)
Rural zone of
Alagoas
8(11.4)
0(0)
Maceió
57(81.4)
2(50.0)
Did not have
prenatal care
5(7.1)
2(50.0)
No
5(7.0)
2(40.0)
Yes
66(93.0)
3(60.0)
First trimester
17(25.4)
1(25.0)
Second trimester
20(29.9)
1(25.0)
Third trimester
25(37.3)
0(0)
Did not have
prenatal care
5(7.5)
2(50.0)
Qualitative variables
City in which
prenatal care
was completed
Table 1. Distribution of sociodemographic variables and sexual
relationships, according to infected and uninfected children
Non
infected
Prenatal care
obtained
Trimester of
pregnancy when
received first
prenatal visit
p-value
Confirmed
case of AIDS in
prenatal care of
pregnancy
Yes
15(23.1)
0(0)
No
50(76.9)
4(100.0)
Use of
antiretrovirals
for the treatment
of AIDS in
pregnancy
Yes
14(21.5)
0(0)
No
51(78.5)
4(100.0)
Trimester of
pregnancy in
which TARV
was used for
prophylaxis
of vertical
transmission
First trimester
9(14.3)
0(0)
Second trimester
21(33.3)
1(25.0)
Third trimester
21(33.3)
0(0)
Did not have
prophylaxis
12(19.0)
3(75.0)
0.031
0.51
0.248
0.366
0.395
0.058
percentage of uninfected children (Table 3). There
is a noted exception of the births in rural areas,
which had the highest percentage of children who
did not receive antiretroviral prophylaxis (ARV)
within 24 hours of life among the group of infected
children, and a tendency for the highest percentage
of children who breastfed among the group of infected children (0.05 <p <0.10).
Table 3. Distribution of care during childbirth and after birth,
according to infected and uninfected children
City in which
delivery
occurred
Interior of
Alagoas
Pernambuco
Initiation
of TARV
prophylaxis in
the child
Breast feeding
n(%)
2(2.8)
2(50.0)
1(1.4)
0(0)
2(50.0)
More than 4
hours
1(1.6)
0(0)
Less than 4
hours
(Including
cesarean
section)
59(96.7)
1(100.0)
Home birth
Use of ARV
during delivery
Infected
n(%)
68(95.8)
Maceió
Time of
rupture of the
membranes (in
hours)
Notinfected
1(1.6)
0(0)
Yes
58(84.1)
1(25.0)
No
11(15.9)
3(75.0)
5(8.5)
3(75.0)
54(91.5)
1(25.0)
Did not
receive
Started in the
first 24 hours
Yes
6(8.8)
2(50.0)
No
62(91.2)
2(50.0)
p-value
0.014
0.982
0.021
0.005
0.058
Table 4. Distribution of outpatient treatment of the child,
according to infected and uninfected children
Non
infected
Infected
n(%)
n(%)
First examination and qualification
of viral load of child completed in
outpatient setting
Yes
63(90.0)
5(100.0)
No
7(10.0)
0(0)
Second examination and
qualification of viral load of child
completed in outpatient setting
Yes
44(80.0)
5(100.0)
No
11(20.0)
0(0)
Third examination and qualification
of viral load of child completed in
outpatient setting
Yes
1(14.3)
5(100.0)
No
6(85.7)
0(0)
Discussion
The limits of the study results refer to the cross-sectional design that performs measurements at a single time, without follow-up period. Was chosen for
the research because it allows to describe the variables and their distribution patterns. As a practical
contribution the results pointed to the need to im-
plement primary prevention of vertical transmission in reference service.
The characteristics of the population studied,
taking into account sociodemographic data and the
type of maternal exposure to HIV, imply an impact on the transmission of the virus. The increased
number of HIV infection cases associated with
the category of heterosexual exposure has been accompanied by an increasing proportion of infected
women: those of childbearing age.(9-14)
The data in this study correspond to findings
in the literature (Table 1), showing alower level of
school education among women. In Brazil, the majority of AIDS cases in women occur in those who
are poorly educated and have less skilled occupations.(4,14-17) The conditions of poverty and social exclusion directly affect the lives of these women and
their descendants. The lack of bargaining power in
sexual relationships characterize an aggravating factor for HIV infection.(17-19)
Table 2 shows that 9.8% of the pregnant
women did not have prenatal care; 82.3% had
prenatal care, and of these, 23.5% initiated consultations in the first trimester of pregnancy.
However, 28.4% initiated prenatal care during
the second trimester, and 30.4% during the third
trimester, showing that the majority lost opportunities for both early diagnosis and for the initiation of antiretroviral prophylaxis.(15,16,20,21) The
prevalence of the drop in viral load is a result of
interventions in the prenatal period, resulting in
the reduction of vertical transmission.(4,5,9,10,16-21)
Different authors, in Brazil and in other regions
of the world, have demonstrated that the period of
major risk of transmission of the vírus is concentrated in the third trimester of pregnancy, and principally at the time of birth. It is known that, when the
viral load is lowered for the mother, there is a lower
possibility of vertical transmission.(4,7,8,10,16,20-23) The
use of antiretroviral treatment in the second and
third trimesters of pregnancy (29.4% and 26.5%,
respectively), showing a low adherence to prophylaxis. Even worse are the numbers (18.6%) of those
pregnant women who did not prophylaxis.
Table 3 shows that 96.7% of women delivered
their child in less than four hours after rupture of
Acta Paul Enferm. 2013; 26(2):158-64.
161
their amniotic membranes, including those by cesarean delivery. This result demonstrates a protection in relation to the adnexal factors, since these
are among those that potentially increase the transmission of HIV.(16,17,23)
In this study, 79.4% of pregnant women (Table
3) received intravenous AZT during labor and delivery, which accounted for 93.1% of the births of
those women that occurred in Maceió, and not in
the interior of the State.
There is a proportion of vertical transmission
that can occur in the intrapartum period and a
lower rate of infection occurs when birth occurs
via caesarean section. Caesarean section in women
infected with HIV may have a clinically important
protective effect to reduce transmission before the
onset of labor, when membranes are intact.(18-23)
Access to health care is different in each region
of the country for HIV-infected pregnant women,
and for their exposed children. Thus, isolated facts
may change the time that the diagnosis of HIV infection on women and the child is made.(23)
In Maceió, in the referral service, an elective
cesarean section has been adopted due to the access these women have for the time of delivery. Although the majority of births took place in Maceió,
a large number of these came from the interior of
the state.
The newborns of HIV-infected women should
receive the oral solution of Zidovudine (AZT) in
the first two hours of life, even if the mothers have
not received antiretroviral drugs during pregnancy
and / or childbirth. Table 3 shows that of the children exposed who received no antiretroviral treatment, three were infected with the virus.(19-24)
Maternal (natural) breastfeeding is an additional risk for vertical transmission indicated in Brazil,
it is systematically contraindicated. One of the most
effective interventions to avoid the return to breastfeeding is to begin the orientation towards formula
feeding during the prenatal period, thus complementing other known interventions to reduce vertical transmission of HIV.(11,23)
Despite orientation in order to prevent breastfeeding and the provision of infantformula, of the
total number of children studied, two of those who
162
Acta Paul Enferm. 2013; 26(2):158-64.
were breastfed presented asinfected with HIV (Table 3). The results show that there is a tendency for
a higher percentage of breastfed children among the
group of infected children (0.05 <p <0.10).
Sociocultural and economic factors may be responsible for the decision to breastfeed, which is
known to increase the risk of viral transmission. In
a study by Succi in 2007,(23,24) children monitored
in the Northeast were proportionally more likely to
be breastfed. Social expectations place mothers in
embarrassing situations and they create socially acceptable excuses to justify not breastfeeding. Health
professionals should support women with HIV to
“deconstruct” the desire of breastfeeding, providing information on how to establish, maintain and
strengthen the bond with her child.(4,5,23,24)
The routine of clinical and laboratory monitoring
of the child exposed to HIV should be monthly for
the first six months, and then a minimum of every
two months beginning at the sixth month of life.(21-24)
Table 4 shows that 90% of charts showed completion of the first examination of the viral load,
in outpatient treatment; 80% had the second examination, and only 14.3% had the third exam.
These data show that the SAE has fulfilled its role in
monitoring these exposed children, and the closing
of cases. However the social reality of Maceió, does
not permit the ideal monitoring recommended to
occur, due to loss of follow up or interruption in the
service due to lack of return to the clinic.
Of the 76 children exposed by vertical transmission to HIV, five were infected. These five
monitored children did not have the opportunities available to them for prophylactic treatment
against vertical transmission of HIV. These results
confirm the urgency of increasing the availability
of HIV testing to pregnant women, and access to
prenatal care in the city of Maceió, with supervision of the actions.
We considered the prevalence of HIV infection
with vertical transmission in this reference service
in the city of Maceió was high (6.6%), as the national disclosed rate was 1%.(23,24)
Demonstrating the partial results achieved in
this research and complying with the practice recommendations from 2007, there was an opportu-
nity in the SAE to offer a group to support women
in the preparation for labor and delivery, under the
guidance of the author of this work. Pregnant women were encouraged and supported to participate
weekly in the group, providing a privileged moment
for clarification of issues unique to them, and their
partner or companion. The meetings allowed us to
talk of intimacy with safety; by promoting strengthening of the path until delivery.
This strategy has enabled prenatal care at the reference center to be better quality and has instituted timely measures to prevent vertical transmission
of HIV. Some of the requirements for changes that
have already been identified still demand attention
and transformation. Other studies are recommended that complement this research, especially with
concern for the issues raised in its development.
Conclusion
2. Guidozzi F, Black V. The obstetric face and challenge of HIV/Aids. Clin
Obstet Gynecol. 2009;52(2):270-84.
3. Brasil. Ministry of Health. Health Secretariat of Surveillance. Health
National Program of STD and AIDS. [Integrated plan for coping with
the feminization of the AIDS epidemic and other STDs ]. Brasília (DF):
Ministry of Health]; 2007. Portuguese.
4. Brasil. Ministry of Health. Health Secretariat of Surveillance.
Health National Program of STD and AIDS. [Recommendations for
the Prophylaxis of Vertical Transmission of HIV and Antiretroviral
Therapy in Pregnant Women: pocket handbook]. Brasília (DF):
Ministry of Health]; 2010. Portuguese.
5. Romanelli RM, Kakehasi FM, Tavares MC, Melo VH, Goulart LH, Aguiar
RA, et al. [Profile of HIV infected pregnant women at a reference
prenatal care service in Belo Horizonte]. Rev Bras Saude Mater Infant.
2006;6(3):329-334. Portuguese.
6. Brazil. Ministry of Health. Health Secretariat of Surveillance. Health.
National Program of STD and AIDS. [Operational plan for the reduction
of vertical transmission of HIV and Syphilis]. Brasília (DF): Ministry of
Health; 2007. Portuguese.
7. Lehman DA, John-Stewart GC, Overbaugh J. Antiretroviral strategies
to prevent mother-to-child transmission of hiv: striking a balance
between efficacy, feasibility, and resistance. PLoS Med. 2009; 6(10):
e1000169.
8. Connor EM, Sperling RS, Gelber R, Kiselev P. Reduction of maternalinfant transmission of human immunodeficiency virus type 1 with
zidovudine treatment. Pediatric AIDS Clinical Trial Group Protocol 076
Study Group. N England J Med. 1994;331:1173-80.
The study confirmed the occurrence of vertical
transmission of HIV in the reference service and
that it corresponded to 6.6%, indicating a high
prevalence. These infected children did not have
the opportunity for prophylaxis, which confirms
the urgency of increasing the supply of HIV testing
for pregnant women and supervision of the actions.
9. Calvet GA, João EC, Nielsen-Saines K, Cunha CB, Menezes JA,
D’ippolito MM, et al. [Trends in a cohort of HIV-infected pregnant
women in Rio de Janeiro, 1996-2004]. Rev Bras Epidemiol. 2007;
10(3): 323-37. Portuguese.
Collaborations
Rodrigues STC contributed to study conception,
the literature review, data collection, input, analysis
and interpretation, drafting of manuscript and final
approval of submitted manuscript. Vaz MJR contributed to study conception, analysis and interpretation, critical revision of manuscript for important intellectual content and final approval. Barros
SMO contributed to research design, interpretation
of data, critical revision of manuscript for important intellectual content and final approval.
12.Moura EL, Praça NS. [Vertical HIV transmission: expectations
and actions of HIV positive pregnant]. Rev Latinoam Enferm.
2006;14(3):405-13. Portuguese.
References
17.Porto JR, Homero MN, Luz, AM. Violence against woman and the
female increase of HIV/AIDS incidence. Online Braz J Nurs. 2003;2(3).
Available at: www.uff.br/nepae/objn203portohomeroluz.htm.
1. Joint United Nations Programme on HIV/AIDS. AIDS epidemic: UNAIDS/
WHO. [update: December, 2010]. Available from: URL: www.unaids.org.
18. Geddes R, Knight S, Reid S, Giddy J, Esterhuisen T, Roberts C. Prevention of
mother-to-child transmission of HIV programme: low vertical transmission
10.Brasil. Ministério da Saúde. Secretaria Executiva. Coordenação
Nacional de DST e Aids. Projeto Nascer / Ministério da Saúde,
Secretaria Executiva, Coordenação Nacional de DST e Aids. Brasília
(DF): Ministério da Saúde; 2003.
11.Moreno CC, Rea MF, Filipe EV. [HIV-positive mothersandnonbreastfeeding]. Rev Bras Saúde Matern Infant. 2006;6(2):199-208.
13.Neves LA, Gir E. [HIV positive mothers’ beliefs about mother-to-child
transmission]. Rev Latinoam Enferm 2006;4(5):781-8. Portuguese.
14.Brazil. Ministry of Health. Secretariat of Health Care. Department of
Programmatic Actions Strategies. Technical Area of Women’s

Health.
[Prenatal and puerperium: qualified and humanized care - technical
manual]. Brasília (DF): Ministry of Health]; 2005. Portuguese.
15.Luo Y, Ping-He G. Pregnant women’s awareness and knowledge
of mother-to-child transmission of HIV in South Central China. Acta
Obstet Gynecol. 2008;(87):831-36.
16.Bastos FI, Szwarcwald CL. [AIDS and pauperization: main concepts
and empirical evidence]. Cad Saúde Pública. 2000;16(Sup. 1):6576. Portuguese.
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in KwaZulu-Natal, South Africa. S Afr Med J. 2008;98(6):458-2.
19.McIntyre JA, Hopley M, Moodley D, Eklund M, Gray GE, Hall DB, et
al. Efficacy of Short-Course AZT Plus 3TC to Reduce Nevirapine
Resistance in the Prevention of Mother-to-Child HIV Transmission: A
Randomized Clinical Trial. PLoS Med. 2009;6(10):e1000172.
20.Iribarren JA, Ramos JT, Guerra L, Coll O, de José MI, Domingo
P, et al. [Prevention of vertical transmission and treatment of
infection caused by the human immunodeficiency virus in the
pregnant woman. Recommendations of the Study Group for
AIDS, Infectious Diseases, and Clinical Microbiology, the Spanish
Pediatric Association, the National AIDS Plan and the Spanish
Gynecology and Obstetrics Society]. Enferm Infecc Microbiol Clin.
2001;19(7):314-35. Review. Spanish
21.Succi RCM. Mother-to-child transmission of HIV in Brazil during the
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years 2000 and 2001: results of a multi-centric study. Cad Saúde
Pública, 2007;23(Supl 3):S379-S89.
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Andiman W. Mode of delivery and vertical transmission of HIV-1:
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Health National Program of STD and AIDS. [Recommendations for
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pocket manual]. Brasília (DF): Ministry of Health; 2009. Portuguese.
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having acquired the human immunodeficiency Virus (HIV): a theoretical
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2010;23(2):206-11.
Original Article
Perceptions and expectations of nurses
concerning their professional activity
Percepções e expectativas dos enfermeiros sobre sua atuação profissional
Augusto Hernán Ferreira Umpiérrez1
Miriam Aparecida Barbosa Merighi2
Luz Angélica Muñoz3
Keywords
Nursing care; Health management;
Qualitative research; Legislation,
nursing; Workload
Descritores
Cuidados de enfermagem; Gestão em
saúde; Pesquisa qualitativa; Legislação
de enfermagem; Carga de trabalho
Submitted
April 22, 2012
Accepted
March 27, 2013
Augusto Hernán Ferreira Umpiérrez
8 de Octubre Avenue, 2738,
Montevideo, Uruguay.
[email protected]
Abstract
Objective: To learn how nurses perceive their professional activity and what are their expectations concerning
the development of comprehensive care management.
Methods: Qualitative research with Alfred Schütz’s social phenomenology approach. The participants were
nine female nurses who worked at public and private hospitals in Montevideo, Uruguay.
Results: The nurses experience the gap between theory and practice, administrative overload, insecurity to
take over care management and pursuit of formal and informal knowledge; they show desires and specific
definitions, autonomy and professional identity, and professional valuation.
Conclusion: The nurses perceive their professional activity as having a gap between theory and practice,
administrative overload, insecurity to take over care management and pursuit of formal and informal knowledge,
with expectations and desires of recovery and definitions of specific duties, autonomy and professional identity.
Resumo
Objetivo: Conhecer como os enfermeiros percebem sua atuação profissional e quais suas expectativas sobre
o desenvolvimento das gestões do cuidado integral.
Métodos: Pesquisa qualitativa com abordagem da fenomenologia social de Alfred Schütz. Os sujeitos foram
nove enfermeiras que trabalhavam em hospitais públicos e privados de Montevideo, Uruguai.
Resultados: Os enfermeiros vivenciam a distância entre a teoria e a prática, a sobrecarga administrativa,
a insegurança para assumir a gestão de cuidado e a busca de conhecimento formal e informal; mostram
desejos de definições específicas, autonomia e identidade profissional, valorização da profissão.
Conclusão: Os enfermeiros percebem a sua atuação profissional como distante entre a teoria e a prática,
sobrecarga administrativa, insegurança para assumir a gestão do atendimento e a busca do conhecimento
formal e informal, com expectativas e desejos de recuperação e de definições de funções específicas,
autonomia e identidade profissional.
Facultad de Enfermería y Tecnologías de la Salud, Universidad Católica del Uruguay, Montevideo, Uruguay.
Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, Brazil.
3
Facultad de Enfermería, Universidad Andrés Bello, Santiago de Chile.
Conflicts of interest: there is no conflict of interest to declare.
1
2
Acta Paul Enferm. 2013; 26(2):165-71.
165
Introduction
Care management is an essential component of the
role addressed in various regulations of professional
practice.(1) It is a process of human resource mobilization in the workplace. Hence, the role of managing nurses will be to lead and support those delivering care by promoting their visibility,(2,3) besides
departing from the work performed by a nursing
team and professional autonomy, expressed by legislation, to enable them to properly take on nursing
decisions and actions.(4)
There is evidence, however, that nurses, in their
practice, experience frustrations and dissatisfactions
in relation to their activities. A study undertaken
in Brazil shows that nurses have some knowledge
about administration and management, but that
they are not able to put them into practice. In addition, this study highlights that nurses see the conflict between how their role is viewed and how it is
actually performed.(5)
It is necessary to change this reality with critical
professionals who promote and defend health, professionals committed to the profession, in so far as
they incorporate the knowledge found in the literature into their practice.(6)
Continuous education is essential for the development of skills with a view to incorporating these
aspects into daily professional practice. The results
of a study about the skills of Brazilian nurses concluded that, in general, there are no formal institutional policies covering professional skills.(7)
It is important to reflect on the healthcare context for the performance of healthcare practices in
management processes in an area where there is a
relationship between nurses and patients, other professionals and the organization, which constitutes
and represents certain characteristics in the nursing
work process and which affects one of its basic areas: care management.(8)
Based on this scenario, this study raises the following questions: How do nurses perceive the tasks
of their professional role in the performance of daily practice? How do they perform nursing care in
relation to medical practice? What are their expectations in relation to their role in the management
166
Acta Paul Enferm. 2013; 26(2):165-71.
of care, based on legislation that defines their professional activity and establishes the obligations of
their profession?
It is important to emphasize the study of the
perceptions, desires and expectations of nurses, to
achieve the profession’s emancipatory objectives.
The results of revealing the activity these professionals perform will certainly contribute to better
understand the subject and to take strategic decisions, which can change the nurses’ situation and
their best professional position.
The objective of this research is to understand
how nurses perceive their professional activity and
what are their expectations in the development of
nursing care management.
Methods
This is a qualitative study, based on the premise
that knowledge about people is possible with the
description of human experience, how it is experienced and how it is defined by its actors.(9) The
phenomenological method was chosen.(10)
The approach adopted was the social phenomenology of Alfred Schutz, which provides a systematic approach to better understand the social
aspects of human action. This approach offers a
way to articulate concepts of intentionality, intersubjectivity, human actions, social relations, expectations and others so that, like in this study,
a better understanding can be achieved about the
social world of nursing professionals.(11) The understanding of this situation, experienced in everyday life, is an analysis of the social behavior in
relation to the nurses’ reasons.
This framework has as its core the social action theory, viewed as the initiator of the changes occurred in everyday life. Actions take place on
the grounds of existing reasons related to past and
present experiences (reasons why) and to the projections that constitute the possibility of the action
itself, early action, imagined, subjective meaning of
the action (reasons for). It is classified as a common
conceptual matrix that translates the actions of a
certain social group.(12)
Umpiérrez AHF, Merighi MAB, Muñoz LA
One of the key concepts of this framework is
the intersubjectivity, which is a precondition of social life. This world does not exist in the subjective
sphere, but in an intersubjectivity in which experiences are reciprocally interpreted. In this sense, the
relationship takes place face-to-face, since there is
always someone available for another’s direct experience when sharing the same space.
Another concept of the social phenomenology
framework concerns the so-called natural attitude,
which is how the human being experiences the intersubjective world incorporated to the world in the
real sense. This attitude is influenced by the knowledge base and by the biographic situation of each
person, the manner in which previous experiences
are kept, and these determine the relevant elements
of action.
The study was carried out in Montevideo, Uruguay, and nine nurses participated, who worked at
both public and private hospitals. Data collection
took place between September and November 2009,
after asking the professionals about their availability
to participate in the study. The statements were obtained through open interviews, which were recorded upon guarantee of privacy, anonymity and confidentiality in relation to the information provided.
Given the nature of the study, the number
of participants was not previously defined and
data collection was finished when the information showed signs of revealing the situation, the
queries of the researchers were answered and the
objectives achieved.(13)
The interviews were guided by the following
questions: How do you perform your daily practice activities in relation to the management of
patient care? What are your expectations in relation to your role as a manager of care xxxxxx? The
statements were fully transcribed, thus ensuring
the integrity of the process and the phenomenological reduction that is aimed at reaching the essence of the ways which are part of the psychic
experience of others.(14)
The analysis of the interviews followed the steps
prescribed by the qualitative data analysis(15) and by
the researchers of social phenomenology:(16) careful
reading of each interview in order to capture the
essence of each experience lived by nurses; grouping
of significant aspects in the statements to form the
categories and their analysis, aiming to understand
the reasons for and the reasons why concerning the
action of nurses and the discussion about the results in the light of the social phenomenology of
Alfred Schütz and other frameworks related to the
subject. The solid categories were composed of descriptions that expressively showed the experience
of the professionals in relation to their professional
activity, named: theory and practice, administrative
overload, pursuit of knowledge, insecurity, specific definitions, autonomy, professional identity and
professional valuation.
The development of the study complied with
the international standards for ethics in research involving human beings.
Results
According to the framework adopted, the participants’ reasons why were represented by the categories developed through the nurses’ statements.
The theory and the practice: […] I try to perform the best possible management. It has not
been too long since I learned and I remember how
it was emphasized at University that, without theoretical foundation and methodology, this profession would not grow. But it is often difficult […]
D1; […] it is in every book, it is the topic of all
classes, but then you start working, get into a routine and end up practicing without thinking about
it; […] I see it daily at my work, both providing
care and teaching and it is interesting to have the
two perspectives. I try to put everything I teach
into practice when providing care, but it is sometimes complicated […] D7.
Another category developed was related to the
administrative overload: […] there are a number of
administrative tasks, but not administrative in relation to administering care or managing the care
delivered to patients, they are matters related to the
coordination of studies, following up visits with the
doctors, issuing pendent prescriptions, it is not easy
[…] D1; […] sometimes, you even forget the care
Acta Paul Enferm. 2013; 26(2):165-71.
167
practices, because what you mostly do, and therefore, what you have practice in, relates to administrative matters…increasingly […] D3; […] as a
matter of need, we have chosen to delegate our activities, which makes me largely realize that we have
lost prestige because we are seen as mere administrators […] D4.
Also in relation to nurses’ experience, the category pursuit of knowledge emerged: […] when
you start your activities in a department, you learn
many things with the colleagues who show you how
to perform the work […] D4; […] you learn with
the young colleagues, those who have just graduated and are able to perform well the management of
the work because they have everything fresh in their
minds […] D6; […] we have to continuously update our skills, search for upgrading courses, always
learn, and perform a good management and activities relating to the care […] this is a need of our
country […] I have learnt with other colleagues, it
is important to see and learn from others […] D8.
The last category, related to the reasons why,
was insecurity: […] I work with nurses’ education.
Sometimes, I think that they are really ready to take
on some things. Sometimes, I see the young guys,
and I think the same […] D7; […] the issue is to
fulfill the obligations […] D9.
The reasons for, according to the adopted
framework, were included in the categories presented below:
The specific definitions arise based on the analysis of parts of the statements: […] I believe that if
there was a law for us, it would be very good that
roles were defined so that we would know that we
have a legislation that has never happened […] D1;
[…] it would be very good in order to define what
we do and what we do not do, that is, that our profession has a meaning […] D2, […] I hope that our
activity area is further defined, as I said, and that
these obligations are accompanied by commensurate financial reward […] D7.
Another category that relates to the expectations
of nurses were autonomy and professional identity,
[…] I am hopeful that our role is clearly defined
and what we, nurses, do and nobody else does what
is ours, that is, to charge our professional identity
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Acta Paul Enferm. 2013; 26(2):165-71.
[…] D2; […] I would say that it is necessary to
define and clarify some issues to legislate on the issue, I suppose that, if there are laws, there will be
a support giving us more autonomy and defining
our area of activity, this is my desire […] D7; […]
I hope that we have more autonomy, recognition,
especially in the social scope […] D8.
Finally, the professional valuation category
emerged: […] I would like us to be valued, it is said
that the nurse is needed, but then we are replaced by
an assistant, without a problem […] D5; […] there
are more things that I would expect: our appreciation, recognition and our recognizing by ourselves,
because sometimes it is so talked about identity and
we are not clear about the meaning of it […] D6.
Discussion
Despite bringing experiences full of meanings, the
results of the present study have, as a limiting factor,
the fact that it was undertaken with nurses from
the same social group in a specific situation. Given
the particularities mentioned herein, it is suggested
that further researches approaching this subject are
carried out in order to reveal other aspects which
were not identified. It is necessary to emphasize that
it offers an interesting contribution to the understanding of the recognition of nurses’ work.
The categories related to the reasons why, theory and practice, administrative overload, pursuit of
knowledge and insecurity show a common feeling
among the groups of nurses, constituting part of
their features.
The role of nurses as managers of care is one
of the profession’s characteristics.(3) The results of
a study concerning the role of these professionals
show difficulties in developing the inherent duties
of their position, thus causing frustration and dissatisfaction, mainly because they are not able to
practically apply their knowledge of management.(5)
The manner in which they perform their activities is related to their acquired knowledge and their
experiences. They cannot apply the theory they
learned during their formal education to the daily work and, as a result, find it hard to implement
what they learned. For this reason, it is necessary to
execute a joint planning of the professional practice with healthcare students, professors and nurses.
This will be a way to coordinate educational and
professional practices.(17)
It can be noted that nurses pursue knowledge
through experiences that are part of their acquired
knowledge. They show the wealth of learning with
others; with those who continually teach and provide opportunities to increase their knowledge baggage and that constitutes an exchange of subjectivity (intersubjectivity),which is a relevant concept in
the social phenomenology approach.(18)
From the nurses’ statements, it is clear that there
is a need for further learning and investing in continuous education, given that some of them feel
uninstructed and outdated. For this reason, they
pursue knowledge and learning in different ways to
meet the demands and needs related to the management of patient care.
The need for formal education and constant
pursuit of knowledge, found in the present research,
also appears in the findings of another study, highlighting that nurses require appropriate training interventions in order to take over the process of management and nursing care with effective tools.(19)
Therefore, it is believed that the post-graduate
course will certainly contribute to the development
of professional knowledge, which will be applied
and, among other issues, will be able to improve
practical skills, with specialized and therapy related
knowledge. This will allow the reorientation of the
nursing practice, based on the development of autonomy and decision making related to their area
of expertise.
As mentioned above, the reasons for specific
definitions, autonomy and professional identity,
and professional valuation show projects and expectations to fully develop the management of care
in their services, with conditions that clearly define
their professional role at a national level.
The nurses also expressed expectations about
the definition of specific roles, increasing the hope
concerning the definition of their professional role.
They wish autonomy and professional identity, and
decision making power in relation to specific issues
of their area of expertise. Their expectations are also
related to the aspiration of being identified and recognized for what they really are, with professional
valuation. These aspects constitute the features of
this group in relation to their projects.
It is important to note that all of those people
who share a social reality feel personal and social
needs as part of a social group. The clear definition
of their roles is the necessary determination for all
people. The world-life of each one is largely composed of these considerations.
According to Schütz, people need to have a
definition of the roles they perform in their daily
practice, which determines their place in society
and in a certain position, and that is part of their
expectations.(20) The need felt by these professionals
is shared and included in the intersubjectivity. The
definition of their roles causes expectations on their
reality and daily experience.(5)
The issue related to the role of nurses is often
addressed and studied in various scenarios. Emphasis is placed on the idea that it is possible to build
the professional identity and put into practice the
specific duties of nurses based on the definition of
their role. Professional nurses have many difficulties
to explain the definition of their role, which affects
the concepts of autonomy of the profession.(21)
Certainly, the development of knowledge in the
country will contribute for the core aspects of the
professional role to emerge, showing the social and
health impact that the professional nursing activity can achieve. The desire related to professional
identity and autonomy can be seen in other studies.
(22,23)
This lack of identity is a relevant characteristic
of the studied group, being their features relevant
elements of the social world.(24)
It is believed, however, that the emancipatory
objectives of the profession can be related to the
essence of care and interaction between nurses and
patients, nurses and families, nurses and the community. For this assistance, it becomes necessary
to understand and internalize the intersubjectivity
that occurs in the relationship between those who
provide care and those who receive and participate
in it. In this reciprocity of intentions, besides the
technical and scientific skills, caregivers need to esActa Paul Enferm. 2013; 26(2):165-71.
169
tablish a process of growth and learning for both
parties while expressing their sensitivity, respect
for values and empathy. In this scenario, care is
no longer a mere intervention, since it becomes a
helping relationship in a professional, holistic and
human way, which leaves room for creativity in
the world of social relationships. This line of action is essential for the profession to obtain the
skills to provide care.
According to some authors, the development of
the professional role, largely identified by a careful
management, is closely related to the autonomy and
professional identity concepts.(23,25) These studies
show that, similarly to the perceptions of the nurses
participating in the present research, these expectations are constantly developing and, for some time,
discussions about the independence of the professional practice have been taking place.
The issue becomes relevant in defining roles, responsibilities and autonomy of nurses. Investigating
these professionals’ experiences in the daily development of their role, and knowing their motivations,
aspirations and behaviors, based on a new and more
experimental perspective, will certainly contribute
to better understand the needs and expectations of
this social group concerning their professional activity. The approach of their professional experience
can be crucial in ensuring consistency between the
care delivered and the patients’ needs.
Based on the approach used in this study, its
development revealed the need for transformation
in the profession, establishing proposals that can be
forwarded through three key inter-related elements:
the empowerment of care management, improving
the profile of graduates, connecting professors to
care; the investment in scientific researches based
on other aspects of care and professional visibility,
with promotion and creation of master’s and Ph.D.
programs; and the development of a professional
emancipation process with professional valuation.
The generation of knowledge through research,
connecting studies with professional practice with
innovation and internationalization, is a way of
showing the contributions offered by the profession
in the healthcare area, promoting the development
of policies, regulations and social behavior, whilst
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Acta Paul Enferm. 2013; 26(2):165-71.
understanding that the future of healthcare depends
on the potential of the professional nursing activity,
which is seen as a live and specialized power and a
support to the system.
Conclusion
The nurses perceive their professional activity as
having a gap between theory and practice, administrative overload, insecurity to take over care management and pursuit of formal and informal knowledge, with expectations and desires of recovery and
definitions of specific duties, autonomy and professional identity.
Collaborations
Umpiérrez AHF; Merighi MAB and Muñoz LA
declare they contributed to the project conception,
analysis and interpretation of data, drafting of the
article, relevant review of the intellectual contents
and final approval of the version to be published.
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Acta Paul Enferm. 2013; 26(2):165-71.
171
Original Article
Social representations of nurses
about tuberculosis patients
Representações sociais de enfermeiros sobre o portador de tuberculose
Ivaneide Leal Ataíde Rodrigues1
Maria Catarina Salvador da Motta2
Márcia de Assunção Ferreira2
Keywords
Nursing; Tuberculosis; Psychology
social; Social behavior; Health
knowledge, attitudes, practice
Descritores
Enfermagem; Tuberculose; Psicologia
Social; Comportamento social;
Conhecimentos, atitudes e práticas em
saúde
Submitted
June 3, 2012
Accepted
April 1, 2013
Ivaneide leal Ataíde Rodrigues
José Bonifácio Avenue, unnumbered,
São Braz, Belém, PA, Brazil. Zip Code:
66000-000
[email protected]
172
Acta Paul Enferm. 2013; 26(2):172-8.
Abstract
Objective: To describe the social representations of nurses about tuberculosis patients.
Methods: A qualitative research was undertaken, based on Social Representations Theory. To produce the
data, the individual interview technique was applied, involving 52 nurses, using a script with closed questions
about the personal and professional profile and another script with 27 open questions that explored knowledge
and action in their daily work with the patients. For analysis, thematic content analysis was applied.
Results: The nurses build social representations based on the stereotyped patients, associate them with the
idea of receptacles of the disease, besides linking vulnerability with illness and social conditions.
Conclusion: Social representations about ttuberculosis patients are organized based on fear, resting on
physical, psychological and social characteristics that help the nurses to outline fhe type-figure of the patient
as dangerous.
Resumo
Objetivo: Descrever as representações sociais de enfermeiros sobre o doente com tuberculose.
Métodos: Pesquisa qualitativa com referencial na Teoria das Representações Sociais. Para produção dos
dados utilizou-se a técnica de entrevista individual, com 52 enfermeiros, utilizando um roteiro com questões
fechadas sobre o perfil pessoal e profissional e outro com 27 questões abertas que exploraram saberes e
fazeres em seu cotidiano com os doentes. Para análise utilizou-se a de conteúdo temática.
Resultados: Os enfermeiros constroem representações sociais baseadas no estereótipo do doente, os
associam à ideia de receptáculos da doença, além de associar a vulnerabilidade ao adoecimento à condição
social.
Conclusão: As representações sociais sobre o doente com tuberculose se organizam a partir do medo
amparado em características físicas, psicológicas e sociais que ajudam os enfermeiros a delinear a figuratipo do doente como perigoso.
Escola de Enfermagem Magalhães Barata, Universidade do Estado do Pará, Belém, PA, Brazil.
Escola de Enfermagem Anna Nery, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.
Conflict of interest: no conflict of interest to declare.
1
2
Rodrigues ILA, Motta MCS, Ferreira MA
Introduction
Tuberculosis has reached the 21st century as one of
the main morbidity and mortality causes around
the world. Its epidemiological importance is illustrated by World Health Organization data, showing
that two billion people have been infected by the
Micobacteriumtuberculosis around the world, leading to eight million new cases/year and the death of
approximately two million people.(1)
In global terms, Brazil figures among the
22 countries with the highest disease burden,
ranking 19th, with considerable incidence levels.
In 2011, 69,000 new cases were notified in the
country, corresponding to an incidence rate of
36.0/100,000 inhabitants.(2)
In the North of Brazil, in the state of Pará,
with a population of 7,581,051 inhabitants, distributed across 144 cities, the state capital Belém
stands out because it notifies approximately
40% of cases in the state. In 2011, 1,497 new
cases were counted, with an incidence rate of
100.0/100,000 inhabitants”.(2)
Tuberculosis is historically considered metaphorical and, since its emergence in human history, the disease has appealed to the imaginary of
those who have contact with it, whether they are
patients, relatives or health professionals.(3) For
several decades, contact with the disease and patients brought no logical explanations for contamination. As a result, the social imaginary received
constant information that circulated in the scientific universe as well as in common sense, with
phantasized and/or stigmatizing explanations that
entailed social and biological consequences, often
necessarily in that order as, due to the lack of scientific knowledge about the casuses and the lack
of effective treatment, the patients had nothing
left but harmless or harmful palliative treatments,
with consequent lethal outcomes. Because of the
stigma surrounding these patients, physical death
was preceded by social death.(4)
Today, advances in pneumology permit an
early diagnosis, immediate treatment and cure.
Diagnosis and treatment are available in the public healthcare network, where patients receive
care from a multiprofessional team.(5) Despite
this favorable modern scenario, tuberculosis is
still feared, and patients continue being victims
of social prejudice.(3)
In the multiprofessional teams, in general,
nurses accompany patients in the course of their
treatment. That has been the case since the start
of tuberculosis control in Brazil, in which patients
play an outstanding role.(6,7) With a view to understanding how these professionals deal with patients in the daily reality of health services, the aim
in this research is to: describe the social representations of nurses working in primary health care
about tuberculosis patients.
Methods
This descriptive and qualitative study was based on
the process branch of Social Representations Theory. This Theory is focused on socially relevant objects, in the attempt to unveil meanings and senses
social groups attribute to them, in order to explain
and act on them.
As common sense theories that link thought and
action, the study of social representations grants access to the meanings the subjects give to an object.
Considered as practical knowledge, they contribute
to understand the positions the subjects take in the
contemporaneous world.(8) Its elaboration process
involve the personal experiences unique and particular to each subject, as well the social experiences,
which are the experiences the subject shares with
the group(s) he belongs to, in social life as well as in
circulating social discourse.
The study contexts were 23 Primary Health
Care Units located in the city of Belém, state of
Pará, in the North of Brazil, where tuberculosis
control has been implemented for more than
five years and which concentrate more than half
of the cases in the city. These units were chosen
because they further the contact between nurses
and patients and support the experience that is
to be evidenced, for the professionals active in
direct patient care as well as for other professionals who, although they are not involved in direct
Acta Paul Enferm. 2013; 26(2):172-8.
173
care delivery, have permanent contact with the
patients at these services, making it important
to understand their representations and behavior
towards the ill as well.
Participants were 52 nurses, 26 of whom deliver care to tuberculosis patients and 26 are active in
other areas at the Units. This number was defined
based on how many nurses worked in patient care
at the time of data collection, i.e. approximately
38 professionals. As the number of nurses in the
other sectors was higher, the researchers aimed for
numerical equivalence between the two groups.
Professionals who had worked at the Unit for less
than one year were excluded, as well as professionals
on leave for any reason or who did not accept to
participate in the study.
The individual interview technique was applied with the help of a script with closed questions about the personal and professional profile,
and another containing 27 open questions, exploring the nurses’ knowledge and activities in
their daily work with patients, their feelings, affection, motivations, actions and the motives for
their responses.
The interviews were fully transcribed and classified based on the questions and respondents,
through the application of the thematic content
analysis technique. The interviews were analyzed
based on the recording units corresponding to
each question, from which the words and thematic phases were taken that constituted the thematic
categories, in accordance with their occurrence and
co-occurrence. These were organized in line with
the tuberculosis patients’ characteristics, in view of
the images the nurses outlined in their statements.
The study development complied with Brazilian
and international ethical standards for research involving human beings.
Results
About the nurses who participated in the research,
50 are women and two men, in the predominant
age range superior to 45 years (46.1%). 61.5%
graduated more than 20 years earlier, 88.5% hold
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Acta Paul Enferm. 2013; 26(2):172-8.
a specialization degree, 73% have a stable employment situation and 77% have more than one job.
Half of the participants gain a monthly income
between six and ten Brazilian minimum wages.
Among clinical professionals, 100% received
specific training, 38.4% have worked at the Unit
between six and ten years and the same period at
the tuberculosis sector. Among professionals active in other function, 69% have worked at the
Unit between one and five years, and 80.7% have
received training.
Concerning the social representations, the stereotype of the tuberculosis patient remains strongly present, with physical, psychological and social
characteristics. Although it seems outdated, the
conception of fear the nurses described continues
strong nowadays. And, despite the whole scientific
evolution to diagnose and treat the disease, this fear
related to tuberculosis patients is still a spectrum on
the loose in society.
The tuberculosis patient: a stereotype
The patients were mainly described based
on physical characteristics, whether considering
weight loss or another characteristics. In the light
of the data, the description involves stereotypes
that were constructed and are predominant in the
social imaginary. The disease is objectified in the
classical figure of “consumption”: skinny, pale,
bowed and weak.
This stereotype does not only decodify the patient, but also underlies the conception that his
physical appearance presupposes a severe illness as,
according to the nurses, guided by scientific rationality, the stereotype of “consumption” would only
be present in advanced stages of the disease. Thus,
according to some testimonies, the stereotype is
conditional to this severity.
It is also highlighted that, when talking about their
representations, the nurses describe the patients’ clinical condition in superlative terms, using words like
“highly” and “super”, which emphasize the patients’
characteristics. When considering tuberculosis, it is
insufficient to state that the disease is in an advanced
stage or that the patient is downcast, the superlative
form is needed, “highly advanced”, “super downcast”.
Psychological characteristics
As it figures in the sphere of feelings, the psychological condition is objectively captured, based
on indicative signs. Hence, the patients’ sadness is
objectified in the “fallen shoulders”, in a somewhat
cowering posture, which metaphorically means
the social weight of the disease they corry on their
shoulders. Similarly, a successful treatment is objectified in perceptible changes in their changes, with
important alterations in the patients’ behavior and
physical appearance.
Social characteristics
In this respect, the characteristics that indicate
personal and social vulnerability are predominant,
from a socioeconomic perspective, which also involves matters of low education and prejudice.
As regards vulnerability, although scientific
knowledge enables them to affirm that the disease
depends on contact with the causative agent, they
associate this vulnerability with the social groups
the disease has affected across history, that is, people who did not receive socioeconomic and social
attention. Hence, they demonstrate their estrangement when witnessing, among these patients, people whom they would not consider part of this
group, due to their distinguished social position,
from a socioeconomic as well as educational viewpoint. Thus, although they seem to demonstrate a
certain degree of naturalization, considering that
the disease can affect anyone, soon, estrangement
appears, indicating that the stereotype of the socially unattended patient remains strongly rooted in
these social representations.
Constructing the type figure: The dangerous patient
The nurses classify the patient figure according to what they consider him to be, using practically immanent expressions. They consider that
tuberculosis patients are not just any patient,
they are distinctive and gain importance because
they are, or so as to seem to be, a receptacle of
microorganisms, representing a source of contamination and transmission. In the attempt
to name the patient, they use expressions like:
a danger, transmitter, source of contamination,
thus informing their representations.
Discussion
The range of this study stands out when considering the number of scenarios and subjects in the
city of Belém, although this is also considered its
limitation. Another limiting factor is the impossibility of gender analysis, in view of the restricted
number of male nurses. Nevertheless, in view of the
sample, the study objective was achieved, showing
that the representations the nurses expressed about
the tuberculosis patients seem to have undergone
little redimensioning over time. While, in the past,
patients needed to show determination to cope
with social prejudice and were captives of palliative
treatment, today, they are encouraged to be equally
determined in order to face similar prejudices and
the strictness of modern chemotherapy.
The Social Representations Theory showed to
be a pertinent theoretical-methodological reference framework in this research, revealing social
representations about the patients, so as to understand how the nurses act, through they meanings
they construct about them. Understanding their
thoughts and actions permits understanding why
they often choose not to attend to these patients.
Without this possibility, they end up providing assistance void of care and lacking quality, as it rests
on fears and prejudices referent to the patients and
their disease.
By unveiling these aspects, this study contributes to the quality of care delivery to tuberculosis
patients. This is relevant when considering that the
way they receive care at health services can make a
difference in their adherence or not to long-term
treatments like that against tuberculosis.
In the context of the nurses’ description of these
patients according to stereotpyes, it should be kept
in min that the definitions of health and disease in
society vary according to individual, family, cultural and social characteristics. In Western communities, the definitions of health include physical, psychological and behavioral aspects. Thus, defining
Acta Paul Enferm. 2013; 26(2):172-8.
175
someone as a patient involves different perception
spheres; in the individual sphere, people acknowledge themselves as ill; in the collective sphere, they
are acknowledged as such by society and two types
of perception can articulate. The list of physical or
subjective experiences involved in this decoding
process of oneself or the other includes perceived
changes in organic functions, which take the form
of limb functioning, emotional conditions and
bodily appearance.(9)
Therefore, by provoking changes in the patients’ physique, which clearly marked them when
the disease was incurable, tuberculosis makes the
nurses objectify patients according to this socially
constructed stereotype, which apparently preserves
reminiscences. Hence, they start to be acknowledged as patiens in society. When associating the
physical weakness with the worsening of the disease,
the nurses use the reified knowledge this idea rests
on, as the clinical evolution of tuberculosis is slow
and, if not diagnosed early, worsens the patients’
physical conditions and consequently changes their
body image, to the extent that it advances without
any medical intervention.
The use of superlatives to describe the patients’
clinical conditions underlines the idea that tuberculosis is not just any disease, it is not just one on
the list of infectious diseases nurses can deal with
in their daily professional or personal life. Despite
knowing that infectious conditions weaken patients,
when referring to patients with tuberculosis, their
description is loaded with symbols, whose explanation lacks superlatives and quantitative gradients.
In the psychological sphere, associating the patients with certain characteristics or feelings is not
new. This practice has been frequent in the social
sphere across the disease history and has continued
for a long time on the patients’ trajectory, serving to
hide a combination of stigmas fed by patients, their
relatives and the medical groups responsible for care
delivery. In that context, the patients were fit into
their characteristic psychological/behavioral model
and did not dare to reject it.(10)
In the sphere of social characteristics, the association between the disease and the subject’s social level marks an apparent transition towards the
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naturalization of the patient’s profile, in view of a
change the nurses describe, towards “almost” equal
conditions and the coexistence of “two types of patients”. Nevertheless, the socioeconomic condition
seems to be the differential.
In view of the different and frightening, in this
case epidemic and incurable diseases, society looks
for explanations and people to blame, as well as
for justifications and victims. Thus, it socially constructs groups that fit into its explanatory model/
justification, in order to accuse or protect them.
These projections onto groups can derive from collective memories, scientific theories or even from
social chatter.(11) This aspect is identified when observing that the nurses project tuberculosis onto
certain groups based on their contact with the
ideas about the disease that circulate in common
sense and in the scientific context.(12,13) According
to them, who rest their representations on stereotype, the disease is a prerogative for socially unattended and physically frail people, while those
without these conditions would be less vulnerable
to it. In other words, the protection of the group
the patients belong to is strong and clearly expressed in their statements.
As a disease that has always been described as
a socially relevant phenomenon, the social representations organized about tuberculosis gained
new meanings and organizations over time, always
accompanying changes in society. In that context,
by organizing their thinking based on the idea of
patients who represent a social danger as they are
bearing the bacillus, the nurses remit to the former
social representations of “consumption”, when patients carried the mark of death.(4)
At the end of the 19th century, because of the
new meanings attributed to the disease in the social
context, patients were no longer seen as victims and
started to be considered as dangerous, because of
their ability to disseminate the disease. This apparently outdated fear, related to disease that aroused/
arouse great mystery, still continues despite new
perspectives. This thought is valid with regard to
tuberculosis, as the entire mystery surrounding its
causes is unveiled and effective treatment is available. But what has been described in this study is
that no science about the disease will be capable of
dispelling the fears it arouses in common sense.(10,14)
In organizing the components of representations about tuberculosis patients, the discourse
mostly remits to the stereotype of “consumption”,
which was socially constructed for them. When
moving the patient figure to the vulnerability axis
of social groups, the nurses acknowledge that part
of this space belongs to the group that legitimately
occupies it: socially unattended people.(14) In that
sense, they manifest their estrangement, identifying
that, on the same vulnerability axis, another space
is occupied by subjects who should not be there,
considering their distinguished socioeconomic and
educational background. This possibility surpasses their understanding when they report on their
experience at the Units, personal and professional
information and official statistics about the disease, which show the predominance of the disease
in the socially vulnerable group. Therefore, this is
a new element in the puzzle that helps to organize
the social representations about patients for these
nurses. This repertoire includes the idea that they
are a source of contamination, giving feedback to
the stereotypes, which in turn reconstruct the type
figure of the patient as dangerous, reinforcing the
professionals’ fearful attitude towards him.
This attitude can guide behaviors and practices in the nursing care context. As, essentially, care
presupposes the idea of proximity with the other, it
is valid to reflect on the conditions it occurs in and
the consequences it entails if the nurses are insecure
and fearful about it. When these affections are mobilized, the patient-nurse relation tends to weaken
and fail, which can result in patients’ non-adherence to treatment, as the professional did not adhere either.
Conclusion
The social representations about tuberculosis patients are organized based on fear, which rests on
physical, psychological and social characteristics
that help the nurses to outline the type-figure of the
patient as dangerous.
Acknowledgements
To the Brazilian Scientific and Technological Development Council (CNPq): research productivity
grant level 1D for Ferreira MA; to the Coordination for the Improvement of Higher Education
Personnel (CAPES) and Universidade Federal do
Rio de Janeiro (UFRJ): partial funding for Interinstitutional Doctoral program, to Universidade do
Estado do Pará (UEPA): Doctoral fellowship for
Rodrigues ILA and partial funding for Interinstitutional Doctoral program.
Collaborations
Rodrigues ILA; Motta MCS and Ferreira MA participated in the conception of the project, data
analysis and interpretation, relevant critical review
of the intellectual contents and final approval of the
version for publication.
References
1. World Health Organization. Global Tuberculosis Control: WHO Report
2011.[Internet]. [cited 2011 out 03]. Available fromhttp://www.who.
int/publicationsglobal_report/en/index.html
2. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde.
Programa Nacional de Controle da Tuberculose. Situação da
tuberculose no Brasil.[Internet] [citado 2013 mar 09]. Disponível em
http://portal.saude.gov.br/portal/arquivos/pdf/apresentacao_dia_
mundial_tb_26_03_
3. Porto A. Representações sociais da tuberculose: Estigma e preconceito.
Rev Saúde Pública. 2007;41(1):43-9.
4. Rosemberg J. [Tuberculosis - historical aspects and realities, its
romanticism and transculturation]. BolPneumolSanit. 1999;7(2):0529. Portuguese.
5. Monroe AA, Gonzales RIC, Palha PF, Sassaki CM, Ruffino Netto A,
Vendramini SHF, et al. [Involvement of health primary care teams in
the control of tuberculosis]. Rev Esc Enferm USP. 2008;42(2):262-68.
Portuguese.
6. Caliari, JS, Figueiredo RM. [Tuberculosis: patients profiles, service
flowchart, and nurses opinions]. Acta Paul Enferm. 2012;25(1):43-47.
7. Almeida Filho AJ, Montenegro HRA, Santos TCF. A nova ordem no
combate à tuberculose no Brasil: implicações para a enfermagem. Rev
Rene Fortaleza. 2009;10(1):114-123.
8. Jodelet D. O movimento de retorno ao sujeito e a abordagem das
representações sociais. Soc Estado. 2009;24(3):679-712.
9. Palmeira IP, Ferreira MA. O corpo que eu fui e o corpo que eu sou:
concepções de mulheres com alterações causadas pela hanseníase.
Texto Contexto Enferm. 2012 abr-jun;21(2):379-86.
10.Clementino FS, et al. Tuberculose: Desvendando conflitos pessoais e
sociais. Rev Enferm UERJ. 2011;19(4):638-43.
Acta Paul Enferm. 2013; 26(2):172-8.
177
11.WachelkeJF, Camargo BV. Representações sociais, individuais e
comportamentos. RevInteram Psicol. 2007;41(2):379-90.
12. Lafaiete RS, Silva CB, Oliveira MG, Motta MCS, Villa TCS. [Investigation
about access to treatment of tuberculosis in Itaboraí/RJ]. Esc Anna
Nery Rev Enferm 2011;15(1):47-53. Portuguese.
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13.Souza KM, Sá LD, Palha PF, Nogueira JA, Villa TC, Figueiredo DA.
Tuberculosis treatment drop out and relations of bonding to the family
health team. Rev Esc Enferm USP. 2010;44(4):904-10.
14.Souza SS, Silva DM, Meirelles BH. [Social representations of
tuberculosis]. Acta Paul Enferm. 2010; 23(1):23-8.
Original Article
Effectiveness of education in health in the nonmedication treatment of arterial hypertension
Eficácia da educação em saúde no tratamento não
medicamentoso da hipertensão arterial
Thatiane Lopes Oliveira1
Leonardo de Paula Miranda1
Patrícia de Sousa Fernandes1
Antônio Prates Caldeira1
Keywords
Primary health care; Health education;
Efficacy; Hypertension; Health
promotion
Descritores
Atenção primária à saúde; Educação
em saúde; Eficácia; Hipertensão;
Promoção da saúde
Submitted
June 5, 2012
Accepted
April 1, 2013
Thatiane Lopes Oliveira
Rui Braga Avenue, unnumbered, Vila
Mauricéia, Montes Claros, MG, Brazil.
Zip Code: 39401-089
[email protected]
Abstract
Objective: To verify the efficacy of health education on the adherence to non-pharmacological treatment in
arterial hypertension.
Methods: Habits related to nutrition, physical activity and use of tobacco and alcohol were analyzed, as well
as assessment of anthropometric and blood pressure levels, before and after the performance of group health
education in 216 hypertensive patients.
Results: There was a statistically significant change in the consumption of legumes, in the adherence to
physical activity, in the reduction of body mass index and abdominal circumference, and in the control of
arterial pressure, after the health education groups.
Conclusion: The proposed health education was effective in incentivizing the adherence to non-pharmacological
treatment in arterial hypertension, evidenced by the relevance of the adoption of these educational strategies
for health professionals.
Resumo
Objetivo: Verificar a eficácia da educação em saúde na adesão ao tratamento não medicamentoso da
hipertensão arterial.
Métodos: Foram analisados hábitos referentes à alimentação, à atividade física e ao uso de tabaco e álcool,
bem como avaliação de medidas antropométricas e níveis pressóricos, antes e após a realização de grupos
de educação em saúde em 216 hipertensos.
Resultados: Houve mudança estatisticamente significante no consumo de legumes, na adesão à prática de
atividade, na redução do índice de massa corpórea e da circunferência abdominal e no controle da pressão
arterial, após os grupos de educação em saúde.
Conclusão: A educação em saúde proposta foi eficaz no incentivo à adesão ao tratamento não medicamentoso
da hipertensão arterial, evidenciando a relevância da adoção dessas estratégias educacionais pelos
profissionais de saúde.
Universidade Estadual de Montes Claros, Montes Carlos, MG, Brazil.
Conflicts of interest: there are no conflicts of interest to declare.
1
Acta Paul Enferm. 2013; 26(2):179-84.
179
Effectiveness of education in health in the non-medication treatment of arterial hypertension
Introduction
Systemic arterial hypertension is a grave public
health problem, considered one of the principle
risk factors for cardiovascular diseases, and responsible for high rates of morbidity.(1) Its control depends on pharmacological and nonpharmacological measures. The nonpharmacological measures
are indiscriminately indicated for the hypertensive patients.(1) These measures include the reduction of alcohol consumption, control of obesity, a
balanced diet, a regular practice of physical activity, and tobacco cessation.(1,2)
Adherence to these lifestyle habits favors the
reduction of blood pressure levels and contributes
to the prevention of complications.(1) However, it
is estimated that only a third of people monitored
in health services have their arterial blood pressure
maintained at desirable levels, and that insufficient
treatment adherence is identified as one of the important determinants of this disease.(3) The family
health teams have, in theory, the best conditions to
promote adherence to treatment of diseases such as
hypertension, because they stimulate a good user/
professional relationship and encourage co-responsibility for treatment. The educational activities
promoted by the professionals stimulate the development of individual autonomy and enables the
discussions and guidelines on how to adopt new
lifestyle habits.(4)
The objective of this study was to verify the efficacy of proposed health education on adherence
to nonpharmacological treatment of arterial hypertension in patients enrolled in family health teams.
Methods
This was an interventional, randomized, uncontrolled, prospective cohort study. The population
consisted of 261 hypertensive patients enrolled in
family health units in the urban area of the municipality of Januária, in the state of Minas Gerais,
southeastern region of Brazil, who were older than
18 years of age. Excluded from the study were those
hypertensive patients who refused to participate in
180
Acta Paul Enferm. 2013; 26(2):179-84.
educational activities. The outcome variables used
were physical activity, diet, smoking, alcoholism
and sociodemographic data. The sample size was
estimated to detect a difference of at least 30% in
the control of arterial hypertension after the educational activities, in relation to an estimated ratio of
50% of people with controlled arterial pressure before initiating the work. A confidence level of 95%
and a sample power of 80% was assumed.
For purposes of data collection, home visits were
conducted before the health education activities. The
first visit was executed with the aim of applying the
individual adult type questionnaire recommended
by the National Cancer Institute – NCI,(5) in order
to gather information about the outcome variables.
After the home visits, the educational intervention was performed. The activities were conducted,
by means of dialogued exposition, specific written
material, sharing experience and evaluation, all
performed in regular encounters lasting 60 minutes and with participation of 12 to 15 people. The
programmatic content was: diet (Dietary Approaches to Stop Hypertension - DASH,(6) physical activity (International Physical Activity Questionnaire IPAQ),(7) abdominal circumference (normal: up to
88 cm - women; 102 cm - men),(8) body mass index
(normal <25, overweight ≥ 25 and <30, obese ≥
30),(9) reduction of the consumption of alcohol and
tobacco. The level of arterial pressure gauged was
classified as optimum / normal / borderline, hypertension stage one and two, and hypertension stage
three / isolated arterial systolic hypertension.(1)
The variables of weight and arterial blood pressure
were assessed in a standardized manner before and after each educational activity. Three months after the
last activity on health education, a home visit was
conducted to collect data, in order to evaluate possible
changes occurred during the research process.
For descriptive analysis, the sociodemographic
and clinical variables were listed.
In the analysis of categorical variables, the Chisquare of McNemar was used, in order to evaluate
the paired data before and after the process of health
education. Data analysis was performed using the
software Statistical Package for the Social Sciences SPSS® 15.0 for Windows®.
Oliveira TL, Miranda LP, Fernandes PS, Caldeira AP
The development of the present study met the
national and international standards of ethics in research involving humans.
Results
(Table 2). In the cessation of alcohol and tobacco,
there were no positive changes observed. Regarding
the anthropometric data, there was a statistically
significant reduction in relation to abdominal circumference in relation to BMI (Table 2).
Table 2. Life habits
The characteristics of the study participants are provided in Table 1.
Variables
Before
After
n(%)
n(%)
Consumption of fruits
Table 1. Characteristics of the research population.
Variables
Gender
n(%)
Feminine
171(79.2)
Masculine
45(20.8)
Age range (in complete years)
Less than 40
5(2.3)
40 to 49
50 to 59
60 to 69
70 to 79
80 years
19(8.8)
48(22.2)
72(33.3)
61(28.2)
11(5.1)
Marital status
Single
19(8.8)
Married
Divorced/separated
Widowed
Ethnicity / Skin color
Yellow
White
Brown
Black
Educational level
Illiterate
Fundamental School Iw
Fundamental School II
Middle School
138(63.9)
06(2.8)
53(24.5)
NA**
Adequate
0(0)
03(1.4)
Inadequate
216(100)
213(98.6)
Consumption of vegetables
NA**
Adequate
1(0.5)
0(0)
Inadequate
215(99.5)
216(100)
Consumption of legumes
0.000
Adequate
186(86.1)
208(96.3)
Inadequate
30(13.9)
08(3.7)
Practice of physical activity
0.030
Very active / active
105(48.6)
102(47.2)
Irregularly active A/B
67(31.0)
87(40.3)
Sedentary
44(20.4)
27(2.5)
Use of alcoholic beverages
0.815
Yes
32(14.8)
34(15.5)
No
184(85.2)
182(84.3)
08(3.7)
13(6.02)
Smoking
149(68.98)
46(21.30)
Yes
16(7.4)
17(7.9)
No
200(92.6)
199(92.1)
1.000
Abdominal circumference
68(31.5)
108(50.0)
30(13.9)
10(4.6)
There was a statistically significant change in
the consumption of legumes, as measured by the
proportions of appropriate use of this type of food
before and after the educational intervention. There
were no significant changes in relation to the consumption of fruits and vegetables (Table 2).
In relation to the practice of physical activity, a
statistically significant improvement was observed
p-value*
0.000
Within limits
69(31.9)
84(38.9)
Greater than limits
147(68.1)
132(61.1)
Body mass index
0.018
Normal
64(29.6)
67(31.0)
Overweight
94(43.5)
100(46.3)
Obese
58(26.9)
49(22.7)
Arterial Pressure
0.004
Optimum, normal & borderline
99(44.9)
144(76.6)
HAS stage 1 and stage 2
73(33.8)
45(20.8)
HAS stage 3 and isolated
systolic
44(20.4)
27(12.5)
Legend: (*) – Chi-square test of McNemar; (**) NA – not applicable
Acta Paul Enferm. 2013; 26(2):179-84.
181
It was also possible to observe an improvement in
blood pressure levels. The blood pressure measures
encountered at the baseline were: SBP = 141.67 ±
23.94 mm/Hg and DBP = 81.94 ± 12.13 mm/Hg.
At the end of the study, the observed values were
131.32 ± 21.63 mm/Hg and 81.76 ± 12.08 mm/
Hg, respectively.
Discussion
The educational groups were characterized as a positive tool in incentivizing the appropriateness of certain behaviors and promoted improvement in blood
pressure levels. However, the study results should be
considered in light of some limitations. Examples of
limitations are the short period of monitoring and
the fact there was no control. It would be important to reevaluate the results over time, in order to
ascertain whether the changes have been effectively
incorporated into the patient’s routine. It should be
emphasized that the study, because it was not controlled, did not permit more evident inferences.
The health education was conceived from an
initial objective, and with adequate planning and
systematic methodology it gives rise to the attainment of good results. The results of this study show
the importance of this strategy and the possibility
for health professionals to make effective use of it in
health promotion.
The predominance of females has been observed in other studies, as well as the prevalence
of the age range between 60 to 79 years.(10-12) The
low educational level observed may impair behavior change by hampering the understanding of the
orientations given, and therefore, it merits special
attention from professionals.(13)
The Dietary Approaches to Stop Hypertension
has had its benefits verified by other authors.(14)
Among the dietary habits discussed, consumption of legumes had a statistically significant
change. Other studies have obtained a significant
increase in intake of fruits and vegetables, after
conducting educational activities.(15) The modification of eating habits is not a simple task, because it is a custom present since childhood, re-
182
Acta Paul Enferm. 2013; 26(2):179-84.
lated to ethnic origin and socioeconomic status
of individuals.(16)
In relation to the practice of physical activity,
there was a statistically significant improvement in
the level of activities performed; several individuals who were sedentary began to practice physical
exercises. The prevalence of physical activity and
the impact of health education on a sedentary lifestyle are variable, according to the literature.(17,18)
The practice of physical exercise may be a behavior
to which it is easier to adhere, since even activities
performed during leisure time are associated with
blood pressure control, but it is found that this
practice is not a reality experienced by most hypertensive patients.(19,20)
No changes were observed in the consumption
of alcohol and tobacco. Different results were found
by Al Qassim, where a 7% reduction in smoking
among participants of a health education program
was observed.(17) Another study in Mexico observed
association between these habits and the control of
arterial pressure, thereby enhancing the benefits of
adequate behavior.(21)
Changes in habits related to the use of tobacco and alcohol are difficult results to achieve in the
short term, so it is essential to continue groups that
reinforce the importance of these behaviors.
Research confirms that the more overweight,
the higher the blood pressure levels.(22,23) In this
study we observed a statistically significant reduction in BMI values. In the abdominal circumference values, a statistically significant reduction was
also obtained. A study of educational guidance,
conducted with hypertensive patients, showed a
reduction in abdominal circumference, body mass
index and, consequently, in blood pressure levels.
(24)
The maintenance of these measures and of body
weight is not an easy task; therefore, the conservation of healthy habits is necessary, such as the adoption of an adequate diet and the practice of regular
physical activity.(25)
In consonance with the changes in some lifestyle habits, we observed a statistically significant
reduction in arterial pressure values, ratifying that
the lifestyle of patients with arterial hypertension
was related to the control of this condition.
Oliveira TL, Miranda LP, Fernandes PS, Caldeira AP
New studies on the subject are desirable in order
to identify the best intervention measures, in order
to attain a greater commitment of patients and to
obtain more effective results from the health promotion actions.
Conclusion
revisão de diretrizes e normas para a organização da Atenção Básica,
para a Estratégia Saúde da Família (ESF) e o Programa de Agentes
Comunitários de Saúde (PACS) [Internet]. Diário Oficial da República
Federativa do Brasil, Brasília (DF); 2011 Out 24 [citado 2012 Jan 12].
Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/
prt2488_21_10_2011.html
5. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde.
Secretaria de Atenção à Saúde. Instituto Nacional de Câncer.
Coordenação de Prevenção e Vigilância. [Household survey on risk
behaviors and morbidity of noncommunicable diseases and injuries].
2003 [cited 2010 Abr 4]. Available from: http://www.inca.gov.br/
inquerito/docs/faseII_tipoadulto.pdf. Portuguese.
The health education proposed was effective in encouraging adherence to nonpharmacological treatment of arterial hypertension, demonstrating the
relevance of adopting these educational strategies
by health professionals.
6. United States. Department of health and Human Services. Your guide to
lowering your blood pressure with DASH. DASH eating plan. Lower your
blood pressure [Internet] [cited 2010 Apr 4]. (NIH Publication, n. 064082). Available from: http://www.nhlbi.nih.gov/health/public/heart/
hbp/dash/new_dash.pdf
Acknowledgements
The Universidade Estadual de Montes Claros - Unimontes. The Municipal Secretary of Health of the
municipality of Januária.
8. Sociedade Brasileira de Cardiologia. I Diretriz Brasileira de Diagnóstico
e Tratamento da Síndrome Metabólica. Arq Bras Cardiol. 2005; 84 Supl
1:1-28.
Collaborations
Oliveira TL participated in the project design, analysis, interpretation, drafting the article, critical revision of the content and final approval of the version
to be published. Miranda LP collaborated with the
project design, analysis and interpretation, drafting
the article and final approval. Fernandes PS participated in the analysis, interpretation and writing of
the article. Caldeira AP participated in the project
design, analysis, interpretation, drafting the article,
critical revision and final approval of the content.
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Original Article
Infection or colonization with resistant
microorganisms: identification of predictors
Infecção ou colonização por micro-organismos
resistentes: identificação de preditores
Graciana Maria de Moraes1
Frederico Molina Cohrs2
Ruth Ester Assayag Batista2
Renato Satovschi Grinbaum1
Keywords
Nursing assessment; Nursing research;
Infection/nursing; Risk factors;
Forecasting
Descritores
Avaliação em enfermagem;
Pesquisa em enfermagem; Infecção/
enfermagem; Fatores de risco;
Previsões
Submitted
June 10, 2012
Accepted
March 27, 2013
Graciana Maria de Moraes
Napoleão de Barros street, 754, Vila
Clementino, São Paulo, SP, Brazil. Zip
Code: 04024-002
[email protected]
Abstract
Objective: Identifying predictors of infection or colonization with resistant microorganisms.
Methods: A quantitative study of prospective cohort was carried out. A descriptive analysis was performed in
order to know the population of the study and a discriminant analysis was performed to identify the predictors.
Results: In this study were included 85 patients with infections caused by resistant microorganisms:
carbapenem-resistant Pseudomonas aeruginosas (24.7%); carbapenem-resistant Acinetobacter (21.2%);
methicillin-resistant Staphylococcus aureus (25.9%), vancomycin-resistant Enterococcus spp (17.6%) and
carbapenem-resistant Klebsiella pneumonia (10.6%). The discriminant analysis identified transfers from other
hospitals and hospitalization in intensive care unit as predictors for the occurrence of infections by the following
groups: S. aureus resistant to methicillin, Acinetobacter resistant to carbapenems and K. pneumoniae resistant
to carbapenems. None of the studied variables was discriminant for vancomycin-resistant Enterococcus spp.
and carbapenem-resistant P. aeruginosas.
Conclusion: The predictors found were: ICU hospitalization and transfers from other hospitals.
Resumo
Objetivo: Identificar os fatores preditores de infecção ou colonização por micro-organismos resistentes.
Métodos: Foi realizado estudo quantitativo de coorte prospectivo. Foram realizadas a análise descritiva, para
conhecimento da população do estudo, e a análise discriminante, para identificação dos fatores preditores.
Resultados: Foram incluídos 85 pacientes com infecções por micro-organismos resistentes: Pseudomonas
aeruginosas resistente aos carbapenêmicos (24,7%), Acinetobacter resistente aos carbapenêmicos (21,2%),
Staphylococcus aureus resistente à meticilina (25,9%), Enterococcus spp. resistente à vancomicina (17,6%)
e Klebsiella pneumoniae resistente aos carbapenêmicos (10,6%). A análise discriminante identificou
transferências de outros hospitais e internação na Unidade de Terapia Intensiva como fatores preditores
para ocorrência de infecção pelos grupos S. aureus resistente à meticilina, Acinetobacter resistente aos
carbapenêmicos e K. pneumoniae resistente aos carbapenêmicos. Nenhuma das variáveis estudadas foi
discriminante para Enterococcus spp. resistente à vancomicina e P. aeruginosas resistente aos carbapenêmico.
Conclusão: Os fatores preditores encontrados foram: internação na UTI e a transferências de outros hospitais.
Instituto de Assistência Médica ao Servidor Público Estadual, São Paulo, SP, Brazil.
Universidade Federal de São Paulo, São Paulo, SP, Brazil.
Conflicts of interest: Batista REA is an associate editor of Acta Paulista de Enfermagem and did not participate
in the review process of the manuscript.
1
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Acta Paul Enferm. 2013; 26(2):185-91.
185
Infection or colonization with resistant microorganisms: identification of predictors
Introduction
Infections related to healthcare caused by microorganisms resistant to multiple antimicrobials
(MDRO, multidrug-resistant organisms) are increasingly prevalent in hospitals. The severity and
extent of the diseases caused by these pathogens
varies according to the affected population and the
institution in which they are found.(1) According
to estimates from the European Center for Disease
Prevention and Control (ECDC), the MDRO infections affect one in every 20 hospitalized patients.
(2)
The increased morbidity and mortality as a consequence of these infections is directly related with
the difficult treatment due to the limited availability of effective drugs.(3)
The colonization or infection with resistant
microorganisms in hospitalized patients has been
receiving increasing attention from the services of
hospital infection control.(4,5) The impact of this infectious complications in the hospital environment
turns into longer hospitalization, readmission, sequels, inability to work, cost increases and mortality. There are no accurate estimates for the global
impact of these infections.(6)
Infections associated with health assistance constitute an important problem worldwide and represent a major threat to the safety of patients.(7)
The Centers for Disease and Control and Prevention (CDC) recommends the implementation
of contact precautions for this population. However, several studies show low adherence to such strategy.(8-10) Besides, there is the risk of delay in the diagnosis of colonization or infection, which increases
the possibilities of transmission among patients.
The virulence and transmissibility of some microorganisms has evidenced the inability of eradicating these agents, hence the need for searching
new methods of control.(11) Studies show it is useful
to perform epidemiological surveillance cultures to
know the real extent of the resistance problem in
healthcare facilities.(12)
Surveillance cultures must be performed in
order to diagnose colonized or infected patients,
who are a reservoir for dissemination of these microorganisms. The purpose of this collection is the
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Acta Paul Enferm. 2013; 26(2):185-91.
early identification of MDRO colonized or infected patients and the immediate deploy of infection
control strategies, reducing cross-contamination
and the risk of developing subsequent infections.
(11)
However, this practice is only strongly recommended in outbreak situations, in endemic cases
that are not controllable with protocol measures
or in risk populations because surveillance cultures
consume material and human resources and have
high costs.(2) Moreover, the influx of MDRO colonized patients does not change and there is a delay
in obtaining culture test results, favoring the spread
of these agents.
Experts recommend deploying contact precautions with the predictors criterion(2,13) as a strategy
to control MDRO dissemination. The objective of
this study was to identify the predictors of infection
or colonization with resistant microorganisms.
Methods
The selected design for the study was cohort, conducted in a tertiary public school hospital which has
979 beds for clinical and surgical treatment, located
in São Paulo (SP). The Grupo Executivo de Controle de Infecção Hospitalar, GECIH (Executive
Group for Hospital Infection Control) develops the
program of hospital infection control based on a
methodology called National Nosocomial Infection
Surveillance System (NNIS). (14)
Data collection was conducted between August
2007 and January 2008 through active search, after the resistant microorganism was identified by
the microbiology laboratory of the hospital, in
accordance with conventional methods of bacterial isolation and identification. The researcher
was notified of the positive result for surveillance
culture and then conducted the follow-up with
patients by filling up a special form until their discharge or death. When the patient had more than
one resistant microorganism, it was considered the
first to be identified.
The demographic data collected were the ones
cited in literature as risk factors for contracting
MDRO: age, gender, origin, underlying disease,
Moraes GM, Cohrs FM, Batista REA, Grinbaum RS
date of hospital admission, length of hospital stay,
antibiotic use, invasive procedures, surgical procedures in the past 30 days, date of the infection related to healthcare and its location, associated diseases, previous hospitalization, admission to intensive
care unit, contact with patients with MDRO and
clinical evolution.(2,5)
MDROs were defined as: methicillin-resistant
Staphylococcus aureus (MRSA); vancomycin-resistant Enterococcus spp. (VRE); carbapenem-resistant
Pseudomonas aeruginosa (PCR); carbapenem-resistant Acinetobacter (ARC); carbapenem-resistant
Klebsiella pneumoniae (KRC).
After collection data were processed using the
Statistical Package for Social Science (SPSS), version 17.0. Initially a descriptive analysis was carried
out to know the population of the study. Afterwards
a discriminant analysis was performed to identify
the predictive factors.
The development of the study met both national and international ethical standards of research involving human beings.
Results
During the study period all the patients with
MDRO were included (n=85). The average age of
patients with microorganisms was 68.7 years with a
standard deviation of 16.4 (Table 1).
The MRSA, ARC and KRC groups showed
equally predictive variables as follows: hospitalization in intensive care units and transfers from other
hospitals (Table 2). Data show that in the relation
between the predictive variables and the ARC group
there was a classification in 94.4% of cases while
with the MRSA group it was 54.5% and with KRC
group it was 44.4%. It is also noteworthy that none
of the elements of the study with predictors was related with PCR and VRE.
Table 2 shows two discriminant functions. The
second function best discriminates “transfers from
other hospitals” as a predictor, while the first function best discriminates the “ICU hospitalization”.
Data in table 3 show the best classification for
the ARC group with 94.4% of accuracy, followed
by the MRSA group with 54.5% and by the KRC
group with 44.4% for the variables “transfers from
other hospitals” and “ICU hospitalization”, identified as predictive factors.
Discussion
This study was limited by the number of patients
included and its conduction in an only healthcare
center, which compromises the generalization of
data.
The results of this study in relation to the resistant microorganisms identified are similar to those
in literature when compared to the population of
ICU patients in other institutions. The prevalent
resistant microorganisms found were: P. aeruginosa,
Acinetobacter baumanni, S. aureus, K. pneumoniae
and Enterobacter cloace.(15)
The prevalence of resistant microorganisms that
frequently cause nosocomial infections is modified according to the study site, with rates between
58 and 71% of PRC and between 43 and 59% of
MRSA.(11,15) In this study however, prevalence of
these agents was lower: 24.7% for PRC and 25.9%
for MRSA.
Previous use of antimicrobial, prior hospitalization and acute kidney injury are identified by several studies as risk factors for colonization with VRE.
(16,17)
Regarding the PRC, some studies have shown
as predictors of colonization the following: presence
of cancer, previous use of antimicrobial and surgery
in the prior four weeks.(18,19) In this study, none of
these variables was discriminant for VRE and PRC,
probably because of the sample size or due to interference of extrinsic factors. Although this latter
case was not studied the transmission of microbial
agents among patients may have occurred.
Studies show previous use of antimicrobial and
prior hospitalization as risk factors for MRSA colonization; for KRC they indicate the presence of
cancer, ICU admission and use of antimicrobials;
for ARC the presence of cancer, high APACHE II
score, ICU admission and exposure to antimicrobials.(17,20-22) In this study, through discriminant
canonical function coefficients of resistant microActa Paul Enferm. 2013; 26(2):185-91.
187
Table 1. Characteristics of patients colonized or infected with resistant microorganisms
Variables
MRSA
n(%)
VRE
n(%)
PRC
n(%)
ARC
n(%)
KRC
n(%)
11(50.0)
11(73.3)
9(42.8)
10(55.6)
5(55.6)
Transfer from other hospitals
2(9.1)
-
1 (4.8)
1(5.6)
4(44.4)
Previous hospitalization in the past 30 days
9(40.9)
10(66.7)
8(38.1)
9(50.0)
3(33.3)
ICU hospitalization
10(45.4)
9 (60.0)
15(71.4)
18(100.0)
8(88.9)
Use of indwelling urinary catheter
12(54.5)
12(80.0)
15(71.4)
18(100.0)
9(100.0)
Use of central venous catheter
12(54.5)
12(80.0)
15(71.4)
18(100.0)
9(100.0)
Use of mechanical ventilation
11(50.0)
10(66.7)
13(61.9)
18(100.0)
9(100.0)
Surgery in the past 30 days
3(13.6)
2(13.3)
5(23.8)
3(16.7)
1(11.1)
1(4.5)
1(6.7)
1(4.8)
4(22.2)
1(11.1)
Gender
Male
Origin
Invasive procedures
Material
Catheter
Blood
14(63.6)
13(86.7)
9(42.9)
7(38.9)
7(77.8)
Secretions
6(27.1)
-
7(33.3)
6(33.4)
1(11.1)
Tendon
1(4.5)
-
1(4.8)
-
-
-
1(6.7)
3 (14.3)
1 (5.6)
-
12(54.5)
5(33.3)
4(19.1)
4 (22.2)
2 (22.2)
Neoplasia
1 (4.5)
1(6.7)
1(4.8)
2 (11.1)
1(11.1)
Chronic renal failure
3(13.6)
4(26.7)
4(19.1)
5 (27.8)
2(22.2)
Acute renal failure
4(18.2)
4(26.7)
3(14.3)
4 (22.2)
1(11.1)
Neurological disease
4(18.2)
5(33.3)
1(4.8)
1(5.5)
1(11.1)
Corticotherapy
5(22.7)
1(6.7)
2(9.52)
5(27.8)
1(11.1)
Urinary tract
3(16.7)
3(18.8)
8(27.6)
1(5.0)
3(33.3)
Wound
1(5.6)
2(12.5)
8(27.6)
6(30.0)
-
-
-
1(3.4)
-
-
Blood stream
4(22.2)
1 (6.3)
3(10.3)
-
-
Pneumonia
7(38.9)
10(62.5)
9(31.0)
12(60.0)
6(66.7)
Skin or soft tissue
1(5.6)
-
-
1(5.0)
-
Abdominal focused
1(5.6)
-
-
-
-
Meningitis
1(5.6)
-
-
-
-
Hospital discharge
10(45.4)
3(20.0)
10(47.6)
5(27.8)
1(11.1)
Death
12(54.5)
12(80.0)
11(52.4)
13(72.2)
8(88.9)
22 (25.9)
15 (17.6)
21 (24.7)
18 (21.2)
9 (10.6)
Urine
Diseases
Diabetes mellitus
Type of infection
Peritonitis
Evolution
Total
Legend: MRSA – Staphylococcus aureus resistant to methicillin; VRE – Enterococcus spp. resistant to vancomycin; PCR – Pseudomonas aeruginosa resistant to
carbapenems; ARC – Acinetobacter resistant to carbapenems; KRC – Klebsiella pneumoniae resistant to carbapenems; ICU – intensive care unit
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Acta Paul Enferm. 2013; 26(2):185-91.
Table 2. Canonical discriminant function coefficients of
resistant microorganisms
Function
Predictive factors
1
2
Transfers from other hospitals
2.119
3.015
ICU hospitalization
1.818
-1.538
(Constant)
-1.482
0.802
Legend: Discriminant analysis was used to identify predictors. ICU – intensive
care unit
Table 3. Classification results of resistant microorganisms
Group
MRSA
n(%)
MRSA
12(54.5)
VRE
VRE
n(%)
PRC
n(%)
ARC
n(%)
KRC
n(%)
Total
0(0.0) 0(0.0)
8(36.4)
2(9.1)
22(100.0)
6(40.0)
0(0.0) 0(0.0)
9(60.0)
0(0.0)
15(100.0)
PRC
6(28.6)
0(0.0) 0(0.0)
14(66.7)
1(4.8)
21(100.0)
ARC
0(0.0)
0(0.0) 0(0.0)
17(94.4)
1(5.6)
18(100.0)
KRC
0(0.0)
0(0.0) 0(0.0)
5(55.6)
4(44.4)
9(100.0)
Legend: Discriminant analysis was used to classify the resistant
microorganisms. MRSA – methicillin-resistant Staphylococcus aureus; VRE
– vancomycin-resistant Enterococcus spp.; PCR – carbapenem-resistant
Pseudomonas aeruginosa; ARC – carbapenem-resistant Acinetobacter; KRC –
carbapenem-resistant Klebsiella pneumoniae
organisms, transfers from other hospitals and ICU
hospitalization were identified as predictive factors
for positive culture for MRSA, ARC and KRC.
Even antibiotics use, no matter what class studied,
did not lead to the occurrence of a particular microorganism, suggesting that the selection promoted by the use of broad-spectrum antimicrobials is
homogeneous, regardless of resistance mechanism.
Multiple predisposing factors have been linked
to emergence and spread of resistant microorganisms, such as declining age, length of hospital stay,
severity of underlying disease, enteral feeding, transfers between units and hospitals, surgeries, exposure
to invasive procedures and use of antibiotics.(23)
The results of ICU admission as a predictor
for MDRO positive culture are compatible with
other studies. ICUs are places where many invasive procedures take place and that concentrate the
severest medical and surgical patients admitted in
hospitals, with higher infection rates, which leads
to a widespread use of antimicrobial, factors that
contribute to the increase of nosocomial infections
and bacterial resistance. Therefore, these units
are the main source of resistant micro-organisms
outbreaks. These patients are at increased risk for
bloodstream infections, pneumonia and urinary
tract infection, having different microorganisms as
etiologic agents.(24,25) Thus, ICUs are the epicenter
of MDRO infections, which can be disseminated
throughout the hospital. Yet, another challenge is
to control the spread outside the hospital environment, in other words, the community, in long stay
institutions or in other places of patients transfers
after hospital discharge.(5)
In this study transfers from other hospitals were
found as predictors for colonization or infection
with MDROs, a factor previously shown in other
studies. Patients transferred from other hospitals
or who have stayed more than 24 hours in another hospital for examinations or procedures may be
colonized or infected with resistant microorganisms
and, upon entering the institution, may show clinical infection by the agent or transmit it horizontally.
Infection control practices have arisen over the
years, to prevent the spread of infections by epidemiologically important microorganisms. Great part
of researches by the Society of Healthcare Epidemiology of America (SHEA) has been highlighted
in the guidelines of infection. Practical guidelines
include contact precautions for MDRO infected
patients, sterile barrier precautions during implementation of central venous catheter, hand hygiene
with alcoholic solutions, surveillance and routine
precautions for MRSA and VRE in areas where
high risk patients are hospitalized.(26)
Thus, patients transferred from other hospitals
should be kept in contact precautions in order to
take cultures of invasive devices, lesion and rectal
swab. Infected and colonized patients should remain
in precaution until discharge. For patients who had
contact with colonized or infected patients it is also
recommended to take cultures of invasive devices,
lesions and rectal swab. ICU colonized or infected
patients must remain in contact precautions until
discharge and when transferred to the hospitalization unit should remain isolated until the end of
treatment, in cases of infection or colonization.(1)
Acta Paul Enferm. 2013; 26(2):185-91.
189
The early implementation of contact precautions is extremely important to contain the spread
of resistant microorganisms in healthcare environments. The high cost of culture tests together
with the delay in obtaining results make the identification of predictor variables, as in this study, a
valuable tool.(1)
Conclusion
The predictive variables for colonization or infection with MRSA, ARC and KRC found in this
study were transfers from other hospitals and ICU
hospitalization. None of the variables studied was
discriminant for colonization or infection with
VRE and PCR.
Collaborations
Moraes GM participated in the conception and
design, analysis and interpretation of data, drafting
the article, revising it critically for important intellectual content and final approval of the version
to be published. Cohrs FM collaborated with the
conception and design, analysis and interpretation
of data. REA Batista collaborated in the writing, revising it critically for important intellectual content
and final approval of the version to be published.
Grinbaum RS participated in the conception and
design, analysis and interpretation of data, drafting
the article, revising it critically for important intellectual content and final approval of the version to
be published.
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Acta Paul Enferm. 2013; 26(2):185-91.
191
Original Article
Organizational safety climate and adherence
to standard precautions among dentists
Clima de segurança organizacional e a adesão
às precauções padrão entre dentistas
Patrícia Helena Vivan Ribeiro1
Maria Meimei Brevidelli2
Anaclara Ferreira Veiga Tipple3
Renata Perfeito Ribeiro1
Elucir Gir4
Keywords
Organizational culture; Universal
precautions; Occupational health
nursing; Public health nursing; Primary
care nursing
Descritores
Cultura organizacional; Precauções
universais; Enfermagem do trabalho;
Enfermagem em saúde pública;
Enfermagem de atenção primária
Abstract
Objective: Check the perception of dentists about safety climate at work in relation to adherence to standard
precautions.
Methods: It is a quantitative, cross-sectional study conducted through the application of the Safety Climate
Scale to a population of 224 dentists who worked in units of primary health care in six municipalities of Paraná.
Results: The total score of 3.43 (SD = 0.88) reveals that dentists have a poor perception of the incentives and
organizational support for adopting standard precautions.
Conclusion: Unsatisfactory safety climate, where the perception of dentists about safety in their work
environment is deficient, demonstrating fragile management actions of support to safety, lack of a training
program in occupational health and deficient feedback to favor the adoption of safe practices.
Resumo
Submitted
June 13, 2012
Accepted
February 21, 2013
Patrícia Helena Vivan Ribeiro
Pernambuco street, 540, Londrina, PR,
[email protected]
192
Acta Paul Enferm. 2013; 26(2):192-7.
Objetivo: Verificar a percepção do dentista a respeito do clima de segurança no trabalho em relação à adesão
às precauções padrão.
Métodos: Trata-se de um estudo quantitativo, transversal realizado através da aplicação da escala de Clima
de Segurança a uma população de 224 dentistas que atuavam em unidades de Atenção Básica de Saúde de
seis municípios do Paraná.
Resultados: O escore total de 3,43 (DP=0,88) revela a baixa percepção dos dentistas a respeito do incentivo
e apoio organizacional para adoção das PP.
Conclusão: Clima de segurança insatisfatório, onde a percepção do dentista sobre a segurança de seu
ambiente de trabalho é deficiente, evidenciando ações gerenciais de apoio à segurança fragilizadas, falta de
um programa de treinamento em saúde ocupacional e deficiência do feedback para favorecer a adoção de
práticas seguras.
Universidade Estadual de Londrina, Londrina, PR, Brazil.
Universidade Paulista, São Paulo, SP, Brazil.
3
Universidade Federal de Goiás, Goiânia, GO, Brazil.
4
Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil.
Conflicts of interest: no conflicts of interest to declare.
1
2
Ribeiro PHV, Brevidelli MM, Tipple AFV, Ribeiro RP, Gir E
Introduction
Methods
A safety climate refers to the perception shared by
managers and workers about the safety of their
work environment through the decision making of
management, standards and practices of safety and
organizational policies that together communicate
the organizational commitment to safety, providing
a real context of the sphere in which labor activities
are carried out.(1,2,3)
This perception is associated with behaviors
of better adherence to safety at work. The organizations where the safety climate presents a higher
score have fewer reports of injuries inherent to the
work process, not only because work was developed
efficiently and safety programs are active, but because the existence of these programs guide workers
to the commitment with management of safety.(4)
One of the safety measures recommended for
healthcare workers is the use of Standard Precautions (SP), measures taken to minimize the risk of
accidents with biological materials inherent to the
practice of these professionals(5) among them, the
dentists. Some peculiarities of this profession favor
the exposure, such as the small field of view in which
they operate, the invasive procedures they perform,
the use of pointed and cutting instruments, of high
speed and ultrasonic which favor the formation of
aerosols and splashes, the close physical proximity
with patients and even accidents due to movements
of the patients at unexpected times.(6)
The low adherence to SP has causes not only in
individual factors as previously thought, but also in
factors related to work and organizational factors
that comprise the climate of safety at work.(4,7)
It is necessary to evaluate both the process and
the factors that may influence the adherence of dentists to safe working practices because even with the
guidelines related to protection of workers, studies
show that adherence to SP is not satisfactory.(7)
Checking up a significant number of accidents
with biological material among dentists and that
organizational factors may be contributing to this
situation(4,5,7,8), this study aimed to verify the perception of dentists about the safety climate at work
in relation to adherence to standard precautions.
It is a descriptive, cross-sectional study of quantitative
approach conducted in six municipalities of Paraná.
The population consisted of all dentists who
worked in the UBS – Unidade Básica de Saúde
(units of Primary Healthcare) of the municipalities
elected to collect data for this research, totalizing
283 dentists. The eligibility criteria were: to be active in the function of dentist and provide direct
patient care. Were excluded those on vacation, on
leave or who had administrative roles, managers or
directors. Thus, the total subjects of the study were
224 dentists.
The data were collected in the period between
July and December, 2008, through individual interviews in the workplace.
To analyze the organizational safety climate in
relation to compliance with standard precautions
among these workers, the Climate Security Scale was
used, translated and validated for Brazil and adapted to the population of dentists. It is a 17-item scale
with scores for each item ranging from one to five.(7,9)
According to this scale, answers are graded expressing
opinions between two extremes: totally agree, agree,
undecided, disagree and totally disagree.
The scores of the Safety Climate Scale were classified as high for values greater than 4.5; intermediate for values between 3.5 and 4.49, and low for
values bellow 3.5.(7)
The construction of the database was performed
using double entry in the spreadsheet application
Excel® for Windows® 2007. The data were exported
to the program Statistical Package for Social Sciences
(SPSS) version 15.0 for analysis. The results were presented using descriptive statistics from the completion of calculations of mean and standard deviation.
The study complied with national and international ethical standards in research involving humans.
Results
Among the 224 dentists who met the inclusion criteria and participated in the study, 143 (63.8) were
female, aged between 30 and 49 years. Regarding
Acta Paul Enferm. 2013; 26(2):192-7.
193
Organizational safety climate and adherence to standard precautions among dentists
the education site (institution) there was a higher
percentage of professionals that graduated in the
Universidade Estadual de Londrina (56.3% - State
University of Londrina) and as for professional experience, the majority had between 11 and 20 years
(51.4%) of practice, working at the institution
(UBS) for less than ten years (50.4%), with a 40hour work week on average.
Regarding the items evaluated in this study, the
mean scores and standard deviations are observed
for each item of the Safety Climate Scale. The total
score of 3.43 (SD=0.88) reveals the low perception
of dentists about incentives and organizational support for adoption of the SP, which can be observed
in table 1.
Observing each of the items separately, it was
clear that none presented high scores. In nine items
intermediate scores were obtained (between 3.5 and
4.49) and eight items had low scores with figures
below 3.5.
Among the low scores, the following items are
presented: 2 which assessed whether the prevention
of occupational exposure to Human Immunodefi-
ciency Virus (HIV) is a priority of the management
(3.2, SD=1.1), 3 related to the provision of specific
training on blood-borne infections (2.7, SD=1.1), 4
where it is checked if improvisations are made in the
UBS when it comes to protecting employees from
infectious diseases (3.3, SD=1.1), 8 which verifies if
unsafe work practices in the UBS are corrected by
supervisors (3.2, SD=1.1), 10 which verifies if in
the UBS the top management is personally involved
in safety activities (3.2, SD=1.1), 11 related to the
existence of a Security Committee (2.3, SD=1.1),
12 on professionals feeling free to notify violations
of safety standards (3.2, SD=1.1) and 15 where it
is questioned the correction of unsafe practices by
colleagues in the UBS (3.4, SD=1.0).
Among the intermediate scores, the following
items are presented: 1 which verifies if in the UBS
employees, supervisors and managers work together
to ensure safer working conditions (3.8, SD=0.9),
5 about the availability of all personal protective
equipment (3.9, SD=3.9), 6 which assesses if in the
UBS all possible measures are taken to reduce hazardous tasks and procedures (3.5, SD=1.0), 7 con-
Table 1. Mean scores and the respective standard deviation for the items that comprise the measure of safety climate, according to
dental surgeons
Mean
score
Standard
deviation
1. In this UBS (Primary Healthcare Unit), employees, supervisors and managers work together to ensure safer working conditions.
3.8
0.9
2. The prevention of occupational exposure to HIV is a priority for the management in this UBS.
3.2
1.1
3. This UBS offers specific training on blood-borne infections.
2.7
1.1
4. In this UBS, improvisations are not made when it comes to protecting employees from infectious diseases.
3.3
1.1
5. All the equipment and materials necessary to avoid my contact with HIV are available and easily visible.
3.9
1.0
6. In this UBS, all possible measures are taken to reduce hazardous tasks and procedures.
3.5
1.0
7. I had the opportunity to be properly trained in the use of personal protection equipment to protect me from exposure to HIV.
3.6
1. 3
8. In this UBS, unsafe work practices are corrected by supervisors.
3.2
1.1
9. The containers for disposal of pointed cutting objects are available and easily accessible in my work unit.
4.3
0.7
10. In this UBS, top management is personally involved in security activities.
3.2
1.1
11. In this UBS there is a safety committee.
2.3
1.0
12. I feel free to notify violations of safety standards in this UBS.
3.2
1.1
13. My supervisor cares about my safety at work.
3.7
0.9
14. In my unit, the leaders encourage the employees to attend lectures on biosafety.
3.6
1.0
15. In this UBS, unsafe practices are corrected by colleagues.
3.4
1.0
16. My work unit has all the equipment and materials necessary for protecting myself from exposure to HIV.
3.8
1.0
17. Employees are taught to be alert and recognize potential health hazards at work.
3.5
1.0
Items of the Safety Climate Scale
Legend: n=224
194
Acta Paul Enferm. 2013; 26(2):192-7.
cerning the professional having had the opportunity to be properly trained in the use of personal protective equipment for protection against exposure
to HIV (3.6, SD=1.3), 9 on the availability and accessibility of safe disposal containers (4.3, SD=0.7),
13 which refers to the supervisor’s concern regarding safety at work (3.7, SD=0.9), 14 which refers
to leaders encouraging workers to attend lectures
on biosafety (3.6, SD=1.0), 16 which refers to the
availability of equipment and materials necessary
for the protection of HIV exposure (3.8, SD=1.0)
and 17 which assesses whether workers are trained
to be alert and recognize potential health hazards at
work (3.5, SD=1.0).
Discussion
It should be considered that this study was developed within the Primary Care sphere, being important to highlight that the data obtained are limited to assessing the safety climate in relation to the
adoption of SP by dentists. It did not aim to analyze
the perception of safety climate by professionals
with leadership positions, nor if it obtained information concerning actions taken in the services and
preventive measures for occupational exposure.
The data shown in this investigation are concerning. They point to a lack of support structure,
support and encouragement by the management of
the studied UBS, where the organizational issue may
influence negatively the adherence to SP by dentists
because the safety climate in the organizations impacts on practices of management for the safety of
workers, showing that the perception of professionals can be valuable or not in the organization.(1,2)
It was found that some actions relevant to the
prevention of occupational accidents such as management involvement, training of workers, existence
of a safety committee, surveillance, among others,
are extremely important for taking care of worker’s
health, and in this study the perception of dentists
in relation to these situations was not satisfactory.
Literature shows that recognizing the importance of the learning process and its implications
in the context of work environment reflects the way
employees perform their activities. As a learning
mechanism training contributes with professionals
so they perform activities with safety, dynamism
and individually, believing that it contributes positively with the organization and the people.(10)
One of the determinant factors which aim to
create and maintain a positive or favorable safety
climate within the organizations are the safety policies and programs.(11) The use of this tool is important because it represents evident actions that intend
to manage and reinforce safety in the workplace.
The Centers for Diseases Control and Prevention
(CDC) include in its recommendations the issue
of administrative responsibility concerning occupational safety in institutions, from the mandatory
existence of a safety committee with an education
program and training, immunization and prevention of exposures until the availability of resources
and feedback about the performance in the adoption of safety measures.(12)
The influence of organizational factors regarding the adoption of SP is known because consolidated actions through safety committees may act
in a way that favors the adoption of these measures
by workers.(13) Therefore, these committees, represented by their managers should become visible by
effectively changing the practice of workers. The
acting of the manager in this process is a very important factor for the professionals because it can
decrease inappropriate actions and increase the
safety of workers.(14)
It is important to maintain a pleasant working
environment, with space to dialogue, exchange of
experiences through training and participation of
managers. An environment with the presence of
punishment can keep workers away of the presence
of leaders, causing discomfort and increasing risks
at work.(15)
Thus, in face of the role of the institution in
what concerns the safety climate, it is necessary that
administrators turn their eyes to this issue, implementing safety programs, improving the employer-employee relationship and preventing accidents
at work with a consequent decrease in costs with
compensation, fall in absenteeism and a better quality of life at work.(2,3,7,16)
Acta Paul Enferm. 2013; 26(2):192-7.
195
Organizational safety climate and adherence to standard precautions among dentists
In institutions with a strong safety climate, workers suffer fewer accidents not only due to security
programs in place, but also because the very existence
of these programs shows employees the commitment
of the administration with their safety.(4,11,16) If there
is evidence that the organization has concerns regarding adherence to safe work practices, then the workers will be more likely to adhere them.(16)
A safety climate in organizations can strongly affect the safety behavior of workers.(14) When the safety climate is deficient, the working process can show
itself vulnerable, putting the health of workers at risk.
Professionals with a high perception of safety in
institutions adopt safe work practices significantly
influenced and may vary between the use of barriers, protection devices, proper and consistent use of
needle safety devices and adherence to recommendations of vaccines, which consequently decreases
the rates of accidents at work.(4)
It is necessary to start examining these dimensions in a more expanded and integrated way, as it
is common that professionals without knowledge of
the real risks of occupational transmission devalue
the adoption of safety measures.(4,7)
The investment in Softwares of Infection Control Management that cover preventive strategies
concerning organizational factors, as well as protocols that provide support in issues related to biosafety is necessary considering that a safety climate
can be defined as the temporal measure of the state
of the safety culture of the institution and can be
measured by individual perceptions on the attitudes
of the organization regarding the safety culture.(14)
In this scenario nurses have an important role,
since most of the UBS are managed by this professional who must return their actions to the issue of
the safety climate, thereby embracing their role of service management along with dentistry professionals.
Conclusion
In this study it was diagnosed an unsatisfactory safety climate where the perception of workers
about safety in their work environment is deficient,
196
Acta Paul Enferm. 2013; 26(2):192-7.
demonstrating fragile management actions of support to safety, lack of a training program in occupational health and deficient feedback to favor the
adoption of safe practices, highlighting the need for
organizational actions through management of a
safety organizational committee.
Collaborations
Ribeiro PHV and Gir E declare to have contributed with the conception and planning of the project, critical review of the interpretation content,
data discussion and approval of the final version
to be published. Brevidelli MM; Tipple AFV and
Ribeiro RP participated of the content critical review, interpretation and discussion of the manuscript data.
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healthcare settings. Atlanta: Center for Disease Control and Prevention;
2007.
13.Gershon RR, Karkashian C, Vlahov D, Grimes M, Spannhake E.
Correlates of infection control practices in dentistry. Am J Infect
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NN. The climate of patient safety: perception of nursing professionals.
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15. Hahn SE, Murphy LR. A short scale for measuring safety climate. Saf
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Acta Paul Enferm. 2013; 26(2):192-7.
197
Original Article
Expectations of the nursing staff
in relationship to leadership
Expectativas da equipe de enfermagem em relação à liderança
Gisela Maria Schebella Souto de Moura1
Juciane Aparecida Furlan Inchauspe1
Clarice Maria Dall’Agnol1
Ana Maria Muller de Magalhães1
Louíse Viecili Hoffmeister1
Keywords
Leadership; Nursing, team; Nursing
service, hospital; Nursing administration
research; Nursing staff
Descritores
Liderança; Equipe de enfermagem;
Serviço hospitalar de enfermagem;
Pesquisa em administração de
enfermagem; Recursos humanos de
enfermagem
Submitted
June 22, 2012
Accepted
March 27, 2013
Gisela Maria Schebella Souto de Moura
São Manoel street, 963, Bairro Bom
Fim, Porto Alegre, RS, Brasil.
CEP: 90620-110
[email protected]
198
Abstract
Objectives: To identify the expectations of the nursing staff in relation to the leadership of a future manager.
Methods: This was an exploratory, descriptive research study, conducted in a university hospital. Data were
collected by means of semi-structured interviews with 62 professionals in the field of nursing. The transcribed
interviews were analyzed according to the reference of content analysis.
Results: Four categories of expectations emerged from the analysis: the behavior of the future manager,
working with the nursing staff, working with other teams, and the work environment. The results showed
that the nursing staff is concerned with the abilities and characteristics of the future manager facing the
assignments in health services.
Conclusion: The nursing staff expected that the future nursing managers would have the abilities for leading
a team and providing a favorable work environment.
Resumo
Objetivos: Identificar as expectativas da equipe de enfermagem em relação à liderança do futuro chefe.
Métodos: Trata-se de pesquisa exploratória, descritiva, realizada em hospital universitário. Os dados foram
coletados por meio de entrevistas semiestruturadas com 62 profissionais da área de enfermagem. Os
depoimentos transcritos foram analisados de acordo com o referencial da análise de conteúdo.
Resultados: Da análise emergiram quatro categorias de expectativas: comportamento do futuro chefe,
trabalho com a equipe de enfermagem, trabalho com outras equipes e ambiente de trabalho. Os resultados
evidenciaram que a equipe de enfermagem preocupa-se com as habilidades e características do futuro chefe
frente às atribuições nos serviços de saúde.
Conclusão: As equipes de enfermagem esperam que os futuros chefes de enfermagem tenham habilidades
para liderar uma equipe e proporcionar um ambiente favorável ao trabalho.
Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
1
Acta Paul Enferm. 2013; 26(2):198-204.
Moura GMSS, Inchauspe JAF, Dall’Agnol CM, Magalhães AMM, Hoffmeister LV
Introduction
The work scene has passed through major transformations due to the advances of robotics and information technology, including in health services,
which have undergone profound changes especially
with regard to the quality of diagnostic and therapeutic methods. However, the dynamics of manager-subordinate, leader-staff relationships and the
process of group work remain topical issues, constituting the focus of studies that address subjects
such as: conflict, productivity, group dynamics, and
leadership, among others.
Nursing consists of a numerous group of professionals whose actions are developed within a
collective environment, being performed by work
teams who need to harmonically string together
their efforts throughout 24 hours a day and seven
days a week, ensuring continuity of nursing care for
inpatients in hospitals. These characteristics are determinants for the existence of models of work organization grounded in leadership and professional
group activities.
In the traditional organization of working
groups, the figure of the person who directs, coordinates, supervises, controls, teaches and monitors
those who make up the team emerges. Within the
environment of nursing, the Law of Professional
Exercise determines that this activity is undertaken, privately, by the nurse.(1) In this way, the nurse
who is responsible for the important role of manager of the nursing staff, in the everyday situations
on the unit, is an essential professional member of
the group, in the search for attending to the needs
of the service.(2)
There are countless adversities that this activity
imposes during the course of work in the role, and
in the leadership of the team, whether in the successes, or even in the difficulties encountered during this
process. This provides nurses new opportunities for
seeking clinical competency and responsibility, expanding the way for career advancement. From this
perspective, the role of manager brings responsibility
to the nurses, but also enables their recognition.
Thus, the development of the ability to lead becomes fundamental for the nurse, in order to im-
prove his professional performance. The leadership
role requires a broad and systematic vision of situations; the nurse should prepare, innovate and search
for new ways to exercise leadership, since the mode
in which that professional leads the staff directly influences a system of care, compromised or uncompromised by the needs of the people.(3)
Nursing care is developed by the staff, so it is
expected that nurses realize the importance of the
process of leadership as one of continuous and dynamic learning, and one that has the capacity for
guiding people to be enthusiastic about the work,
in order to achieve common goals.(4) In this way,
the nurse leader may be the motivator of strategies
that involve the entire team for the performance of
nursing actions. The literature about leadership indicates, over the years, that the nurse who occupies
this position must display certain characteristics,
such as: having skill in interpersonal relationships,
possessing the ability to make decisions, flexibility,
creativity and innovation, as well as supporting and
facilitating the development of work processes.(5)
Besides these attributes, it was emphasized that
the leader must sufficiently understand the peculiar
situations she will face, to correctly choose the most
appropriate strategies in each context.(6) In the daily
challenge of exercising leadership, the frank, open,
direct and transparent communication of the nurse
manager emerged as indispensable to the conduct
of teamwork, enabling the identification of this
need, whether in formal or informal moments of
the work, to reduce gaps in the process. Leadership,
when grounded in knowledge and in technical, administrative and relational abilities strengthens the
team competencies and creates security in the performance of activities.(7,8)
The study presented in this article analyzed
the expectations in relation to the future leadership of the manager, from the perspective of
the subordinate and in a context where this subordinate participates in a consultative process
for the selection of the managers. The study was
conducted in the environment of a public university hospital that, for many years, has adopted
a participatory process of choice for the nurse
managers.
Acta Paul Enferm. 2013; 26(2):198-204.
199
Expectations of the nursing staff in relationship to leadership
This process is conducted every four years. The
occupants of the leadership positions of the service
and unit are chosen by a consultative process, in
which a slate of three names is used for subsequent
appointment by a formal act of the president. It
is noteworthy that nursing is the only area in the
structure of the hospital that conducts the process
in this way. The other areas of the institution follow
the traditional model of the decision being made by
the chief executive.
The focus of the study was on the process of
selecting unit managers, this article is aimed at
discussing the specific objective of identifying the
expectations of the nursing staff in relation to the
leadership of the future manager.
Methods
This was an exploratory study with a qualitative approach, conducted at Hospital de Clínicas de Porto Alegre, a member of the network of hospitals of
the Ministry of Education. At the time of data collection, this hospital had 749 beds and 4,416 employees; 1,841 were in nursing, with 441 of these
being professional nurses. Sixty-two nursing staff
participated in the research, including nurses, nursing auxiliaries and technicians, representing the 34
sectors that had nurse managers in the hospital. The
sampling used was a probabilistic, simple random
sample, through a lottery among the active nursing
staff, ensuring the representativeness of a technical
or auxiliary nurse, and one professional nurse for
every sector of the institution. The inclusion criterion adopted was that the staff selected had voted
in the last consultative process of choosing the unit
managers. Due to the recurrence of words and, consequently, the themes addressed, data collection terminated with the 62nd interview.
For data collection, the semi-structured interviews conducted were recorded, in which the participants expressed their opinion about the issues
included in the proposed script. Data were collected
between June and September of 2009.
After the literal transcription of the information,
we proceeded to read and analyze the testimonies in
200
Acta Paul Enferm. 2013; 26(2):198-204.
search of units of meaning, conforming to thematic
category analysis.(9) This process resulted in categories that enabled the discovery of the expectations
about the relationship of the future manager and
her performance as a leader of the team. To ensure
the anonymity of the information in the presentation of results, the subjects’ statements were coded
into numbers, in the order in which participants
were interviewed.
The development of the study followed national
and international standards of ethics in research involving human beings.
Results
The study participants included 30 nurses (48.4%)
and 32 nursing auxiliaries or technicians (51.6%).
The majority of participants were women (83.9%),
with 45 participants between 31 and 50 years of
age (72.5%). In relation to the working time, only
nine respondents (14.5%) had less than six years of
work experience; the other 53 subjects (85.5%) had
worked more than six years and had participated in,
at a minimum, two processes of selecting the managers at the institution.
Expectations in relationship to leadership
of the future manager
Content analysis of the interviews allowed the
identification of the presence of four thematic axes
that gave rise to the categories of expectations: behavior of the future manager, working with the nursing staff, working with other teams, and the work environment.
The category, behavior of the manager, approached aspects related to the perception of the
team regarding the way to be a nurse. It was composed of words that expressed the importance for
the manager to remain impartial and just when
dealing with issues that interfered with the dynamics of the group, and to seek self-development
for this, thus contributing to new knowledge for
the team.
“[...] that she is serious, competent, transparent, peaceful. That she has the maturity to be
able to talk about the good and bad things. “(E36)
“Impartiality, justice and recognition of the employees that actually work.” (E41)
“That she continues always this way [...] she
protects everyone, she tries to be just with everyone, she shares the overtime, she divides the open
times.” (E44)
The second category, working with the nursing
staff, brought together the testimonies mentioning that the future manager should be someone
who allowed frank and open communication,
that had the ability to recognize and attend to
the needs of the team by giving support whenever necessary, and seeking harmony in the workplace, working in favor of unity and integration
of the group.
“[...] That the manager always maintains an
open channel with the group, that she understands and really stimulates, she also seeks this
understanding.” (E01)
“I hope it is a manager determined to learn a
great deal, to build together with the group, who
may have a power of problem solving with our demands of the nursing staff [...], participatory, who
wants to listen a lot, that has feedback with the
employee. “(E09)
“[...] is to have a participative management,
where everyone can truly exercise his role in context. You have a relationship, a harmonious working
environment. “(E13)
“Appreciation of the professionals on the unit.
An issue of being able to work with people, of
knowing how to coordinate. “(E14)
Expectations of working with other teams was
an emerging category, which inserted aspects related to decision-making ability and the recognition of the manager as the representative of the
group by the other professional categories.
“[...] strong person, important in the decisions,
especially when it involves other managers, primarily of the medical staff.” (E34)
“We always expect the best [...] the manager is
the representation of all, both nurses and the nursing technicians, which is ... that she defends us in
any circumstance, I think that ... working well, with
the manager, with the nurses, with the technicians,
with the medical staff. “(E51)
And in the fourth category, expectations of the
performance of the manager in relation to the work
environment, groups of interview excerpts related
to the sector, what this hospital referred to as the
“unit”, where the team works, such as: improvements to be implemented in the unit; the possibility of changes; the need to make things work; the
implementation of proposals for the campaign; and
zeal for quality nursing care for the patients.
“[...] to be able to maintain a great quality of
work, of nursing care.” (E13)
“So, we have a good expectation because she
volunteered to change the things that she thought
were not right.” (E25)
“That she fulfills what she exposed as the items
that she chose as her mandate.” (E26)
“[...] that she wants to improve the work process
that happens here today, in order to deliver a higher
quality of work [...] a person engaged with these issues, motivated to make those improvements.” (E53)
Discussion
The discussion about the expectations in relation to
the future manager revealed genuine considerations
of the context where the process is deployed. However, the exploratory and descriptive design should
be considered as a limitation of this study that,
while allowing a deeper understanding of the phenomenon, it did not allow for making comparisons
and generalizations. On the other hand, although
the study was conducted in a single university hospital, the discussion can contribute to the understanding of similar situations experienced in other
services inserted in academic settings.
The testimonies of the nursing staff expressed, in
practice, the concern for electing a unit manager who
could attend to the needs of the staff and the work
sector. In addition, we identified aspects relating to
the perception of staff regarding the way to be a nurse
and the peculiar characteristics that she must possess
in order to contribute new knowledge to the staff.
Acta Paul Enferm. 2013; 26(2):198-204.
201
The predominance of women in the positions
researched arose from the socio-historical aspects of
the profession. In this sense, the presence of women was underscored as a positive factor, since women were considered to be holistic, they engaged in
participative leadership practices and tended to encourage staff more than male leaders.(10) In dealing
with the professional experience in this hospital,
the majority of respondents had worked there for
several years, and it was understood that they had
previous experiences, drawn from other selection
processes of choosing of the manager.
When they mentioned the expectations regarding the behavior of the manager, the interviewees reported that nurse managers needed to
share knowledge to guide and equip her team in
the clinical area. This fact points to the importance
of knowledge supporting professional practices;
so, the search for quality patient care is integral to
improving the work team.(11) To invest in qualification of the group, in order to obtain results that
will meet the needs of the health services users, is
a constant need.(12)
Respondents shared that they expected that
the nurse managers would be able to mediate the
issues involving the work group, acting in a competent way, developing skills to know what to do,
and being just in their decision making. In this
perspective, managers needed to be flexible and
able to adapt their actions according to the peculiarities of each context, acting in a coherent way
with the situation experienced and characteristics
of members of the team.(13) The professional nurse
needed to share certain skills to work in management of the service, bearing in mind that the manager is considered to be a reference for staff members, for the other professionals from other areas,
as well as for the users.(14)
The results showed that the research subjects
expected that the manager could integrate the
nursing staff when performing activities, promoting a healthy environment for work, with the
establishment of bonds of trust and reduction of
conflicts. Thus, it was important that the nurse,
in a conflictual situation, demonstrated consistent conduct, was proactive, flexible and adopted
202
Acta Paul Enferm. 2013; 26(2):198-204.
strategies to manage such events.(15) These recommendations come to mean that “[...] the interpersonal dimension and human competence of
the nurse leader is a motivating factor and support for teamwork.”(8)
The respondents, in general, expected that the
performance of the manager would occur in a joint
manner with the team, that is, in the development
of the activities, in the construction of routines, or
even in the resolution of impasses together with the
group. These ideas suggested a model of participative management, that is, the organization of work
must be done so that all nursing professionals are
involved in the majority of decision-making, in the
same way and at the same time.(16) It is worth mentioning that the promotion of good nursing care is
favored when the members of this team feel satisfied
in their work environment, providing opportunities for their behaviors of caring for the patients, expressing the full use of their skills and potentials.(17)
The category attending to working with other
teams refers to the way in which the nursing team
hopes that the manager is perceived by other multidisciplinary teams. In this category, the statements
highlighted the relationship with the medical staff,
a relationship somewhat dichotomous and, sometimes, conflictual, but understood as something
that is still being constructed and in the process of
evolution to strengthen the bond of the actions of
the two professions. In the interface of work with
different professionals, communication between
teams arises as an element that favors the approximation of the various fields of knowledge in the
professional relationship, enabling the exchange of
knowledge and understanding of each professional
about her role in the care of the client.(18)
The work of professionals integrated in the three
areas considered essential pillars of the institution (administration, nursing and medicine) represented the
equilibrium point of the health services and contributed to the quality of care.(19) The nursing team expects
that the manager attends to the aspects of the work
environment, which constitutes the fourth category of
the study. The expectations centered on the possibility
of changes and improvements in the working sector,
whether in relation to the structure, human resources,
or even with regard to the quality of services provided
to customers. In this respect, the statements revealed a
concern in providing a quality service to users. Therefore, the nurse, to manage the activities of her work
team, must be attentive to issues focused on the priorities of service and develop strategies that may help
in decision-making, thus enabling improvements in
services of health.
The human relationship is an essential tool for
nursing, and, it is made viable by means of adequate
communication, in order that the nurse can manage
the actions and needs of the nursing staff. Studies
highlight that the communication skill is a prominent
factor in a leader.(5,20) The articulation among leadership and communication permits the nurse to work
actively on the problems and to promote changes
within the work sector as desired. Therefore, the greater utilization of relationship-oriented leadership, defined as giving feedback, and the support of necessary
changes in the structure of the service facilitating the
realization of the work by other people involved in the
process, by providing staff satisfaction and, quality of
care.(21) Determination and quality of health care have
been recognized as a result of the actions of the teams
who develop them.(22) Thus, the nurse, to manage human resources, needs to be attentive to strategies to be
used with the team to facilitate the achievement of the
objectives of the services.
of the Group of Research and Post-Graduation
(Pesquisa e Pós-Graduação, GPPG) of the Hospital
de Clínicas de Porto Alegre (HCPA).
Conclusion
6. Bernardes A, Cummings G, Évora YD, Gabriel CS. Framing the
difficulties resulting from implementing a Participatory Management
Model in a public hospital. Rev Latinoam Enferm. 2012;20(6):114251.
The expectations identified were: the nurse manager
should be able to work with the nursing staff, being sensitive to the needs of the group, establishing
open channels of communication and developing
participatory processes of management, anchored
in the realization of the problems encountered in
the service and the needs ellaborated by the team.
The attitude of impartiality and justice, as well as
the ability to make decisions contribute to the work
environment and to the team.
Acknowledgements
This study received support of the Research Incentive Fund (Fundo de Incentivo à Pesquisa, FIPE)
Collaborations
Moura GMSS, Inchauspe JAF, Dall’Agnol CM,
Magalhães AMM and Hoffmeister LV were responsible for developing the theoretical framework
and critically contributed to the intellectual development of the article. Hoffmeister LV performed
the step of collecting and organizing information.
Moura GMSS and Inchauspe JAF were responsible
for preparing and forwarding the manuscript. Moura GMSS oversaw the development of the article.
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Original Article
Quality of life of patients with
stroke rehabilitation
Qualidade de vida de pacientes com acidente
vascular cerebral em reabilitação
Edja Solange Souza Rangel1
Angélica Gonçalves Silva Belasco2
Solange Diccini2
Keywords
Quality of life; Stroke; Nursing; Nursing
Research; Public Health Nursing
Descritores
Qualidade de vida; Acidente vascular
cerebral; Enfermagem; Pesquisa em
enfermagem; Enfermagem em saúde
pública
Submitted
August 5, 2012
Accepted
February 21, 2013
Edja Solange Souza Rangel
Doutor Jorge de Lima street, 113,
Trapiche da Barra, Maceió, AL, Brazil.
Zip Code: 57010-300
[email protected]
Abstract
Objectives: To evaluate and correlate quality of life and depression of patients in rehabilitation after stoke.
Methods: A transversal study conducted in two rehabilitation services with patients after stroke. Information
collected included sociodemographic data, the Medical Outcome Study Short-form 36 - item Health Survey,
the Stroke Specific Quality of Life Scale, the Barthel Index and the Beck Depression Inventory.
Results: The sample consisted of 139 patients, with a mean age of 59.4 years; 59% were male. The general
and specific quality of life scores were compromised. According to the Barthel Index, 49.6% of the patients
presented moderate to severe dependency, and 49.7% had depressive symptoms according to the Beck
Depression Index; there was no positive correlation between these data and general and specific quality of life.
Conclusion: General and specific quality of life of patients in rehabilitation, after stroke, presented compromised
domains.
Resumo
Objetivos: Avaliar e correlacionar a qualidade de vida e depressão de pacientes após acidente vascular
cerebral em reabilitação.
Métodos: Estudo transversal realizado em dois serviços de reabilitação, com pacientes de acidente vascular
cerebral. As informações coletadas foram sociodemográficas, o Medical Outcome Study 36 - item short-form
health survey, o Stroke Specific Quality of Life Scale, o Índice de Barthel e o Inventário de Depressão de Beck.
Resultados: A amostra foi constituída de 139 pacientes, idade média 59,4 anos e 59% eram homens.
Houve comprometimento dos escores da qualidade de vida geral e específica. Segundo o Índice de Barthel
49,6% dos pacientes apresentavam dependência moderada a severa e 49,7% tinham sintomas depressivos,
conforme Inventário de Depressão de Beck, não havendo correlação positiva entre estes dados e qualidade
de vida geral e específica.
Conclusão: A qualidade de vida geral e específica dos pacientes com acidente vascular cerebral, em
reabilitação, apresentou domínios comprometidos.
Universidade Estadual de Ciências da Saúde de Alagoas, Maceió , AL, Brazil.
Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
1
2
Acta Paul Enferm. 2013; 26(2):205-12.
205
206
Introduction
Methods
Stroke is frequent in adults and is the second
leading cause of death in the world and the
first cause of functional incapacity for activities
of daily living. According to the World Health
Organization, 15 million people present with
stroke annually, and of these five million die as
a result of the event and a large part of the survivors present physical and/or mental sequelae.
Discrete changes are manifested by 37% of the
patients after stroke, 16% present moderate incapacity, 32% present intense or severe changes
in functional capacity, and others depend on a
wheelchair or are confined to bed. The sequelae generate economic, social and family impacts,
while 15% of the patients present no deficit in
functional capacity.(1,2,3)
The patients with physical and/or mental sequelae require dynamic continuous, progressive
and educational rehabilitation, to attain functional restoration, family, community and social
reintegration, as well as to maintain the level of
recuperation and quality of life.(4)
International research has addressed and
function after stroke, but in Brazil the studies are
limited. The stroke is a sudden event and it affects
the individual and the family who, in general, are
not prepared to deal with its sequelae, which are
responsible for a large portion of retirement due
to disability.(5,6)
The study of conducted in patients who had
experienced a stroke showed major compromise
in the domains of immediately after stroke, and
during the rehabilitation showed improvement
in some domains. The domains most affected
in patients in these studies were: physical function, emotional role, social role, vitality, mental
health, and general state of health. The domain
least compromised in other research was that of
pain.(7,8)
The objective of this study was to evaluate the
of patients in rehabilitation after suffering a stroke,
and to correlate it to sociodemographic, clinical and
functional variables.
This was a transversal study conducted in two rehabilitation services in the city of Maceió, northeast of Brazil, in the state of Alagoas, in the Physical
Medicine Service of the Municipal Post and the Association of the Physically Disabled. The inclusion
criteria were: patients 18 years of age or older, with
more than three months in a rehabilitation program
for stroke. Exclusion criteria were: patients with
aphasia, deafness or significant decrease in hearing,
and patients with cognitive disorders that prevented
understanding of the questionnaires.
The sample size calculation considered a sampling error of 0.08% and data from the local Unified Health System provided hospitalization numbers for public and private hospital patients with
ischemic and hemorrhagic acute stroke, in 2007.
From the 1.231 hospitalizations during that period,
the sample size calculation defined a need for 139
patients for this study.
The data collection instruments considered
sociodemographic, economic and clinical data
of the patients; questionnaire Medical Outcome
Study Short-form 36-item Health Survey,(9) questionnaire Stroke Specific Scale,(10) the Barthel Index(11) and the Beck Depression Inventory.(12)
The generic questionnaire of , the Medical Outcome Study Short-form 36-item Health Survey (SF36), was translated and validated in Brazil and is
composed of eight dimensions. The socre of the
dimensions ranges from zero (worst state) to 100
(best state).(9)
The questionnaire specific for patients with
a stroke, the Stroke Specific Scale – SSQOL
(SSQOL), was translated and validated in Brazil
and contained 49 items, divided into 12 dimensions. The minimum score is 49 points and the
maximum is 245 points, where the higher the
points obtained the better the . A study in Germany conducted with this instrument defined
low as scores less than 60% (<147 points), and in
the present study the same criterion was used.(13)
The Barthel Index is composed of ten items,
and evaluates functional independence in patients
Acta Paul Enferm. 2013; 26(2):205-12.
Rangel ESS, Belasco AGS, Diccini S
with cerebrovascular disease or with other neurological conditions. The score varies from zero to
100, with scores less than 45 considered to be severe dependency for performing activities of daily
living; major dependency was between 45 and 59;
moderate dependency was considered to be between 60 and 80; minor dependency was between
81 and 100.(11)
The Beck Depression Inventory was validated and translated in Brazil, and composed of 21
items that identify dysphoric or depressive signs
and symptoms. Each question has four alternative
response options that describe traits that characterize these conditions. The responses vary between
zero (absence of symptoms) and three (very accentuated symptoms). For classification in this study
we considered values of up to 15 points as lacking
signs of depression; between 16 and 20 points as the
presence of dysphoric symptoms; and more than 20
points, as the presence of depressive symptoms being evident.(12,14)
The research subjects were randomized and the
data were collected in the previously mentioned
health services. The descriptive analyses of the qualitative variables were presented in absolute and relative frequencies, and for quantitative variables the
measures of distribution (mean, standard deviation,
median and range) were used.
The student’s t-test was used for comparison of
the domains of the SSQOL for two categories of
response, with 5% considered to be the level of
significance. The ANOVA test was used to compare the SSQOL with more than three categories
of responses. In these cases of differences, adjustments were made using the Brown Forsythe test and
the Bonferroni test, with 5% considered to be the
level of significance. The Pearson correlation coefficient was applied to verify correlation between
the SSQOL, quantitative variables, SSQOL with
the SF-36, Barthel Index and the Beck Depression Inventory. The criteria for classification of
the correlation coefficients were: moderate (0.5 to
<0.7) and high degree (>0,7). A regression analysis was completed between the SSQOL scores and
the sociodemographic variables and SF-36 scores,
Barthel Index and the Beck Depression Inventory.
For the variables that presented at least a moderate
correlation, we used the Stepwise test. The statistical application used was the Statistical Package
for the Social Sciences (SPSS) version 15.0, and the
level of significance for these tests was 5%. The
research was developed attending to the national
and international ethical norms for research with
human subjects.
Results
Of the total of 181 patients evaluated, 139 were
included and 42 patients were excluded: two due
to death, one refused, and 39 for limitations in
speech, hearing and/or cognitive function that
compromised communication at the time of
data collection. Among these participants, 59%
were men, the mean age was 59.4 years, 59%
were married, 59% had completed primary education, and 67.6% earned the minimum wage
(Table 1).
The most compromised dimensions of the
SF-36 were: functional capacity, physical aspects,
general state of health, social and emotional aspects. The most compromised dimensions of the
SSQOL were: mobility, work, upper limb function, behavior, family relationship, social relationship, and energy. A large part of the patients
(49.6%) presented moderate to severe dependency
for activities of daily living, and 49.7% of patients
demonstrated the presence of dysphoric or depressive symptoms (Table 2).
Many correlations of moderate and high degree
were encountered between the dimensions of the
questionnaires administered to the patients with
stroke, in rehabilitation, that demonstrated compromise in various aspects of their lives and decline
in their (Table 3).
The level of dependence on the caregiver, the
number of stroke, the level of education, female
gender and higher number of individuals dependent on the salary were variables that negatively interfered with specific (Table 4).
Acta Paul Enferm. 2013; 26(2):205-12.
207
Table 1. Characteristics of patients with stroke
Characteristics
Gender
Male
Female
Age (years)
Education
Illiterate
Primary School
Middle School
Higher Education
Salary
No salary
Minimum wage
More than one time the minimum wage
Indiciduals dependent on income
Marital status
Married
Single
Divorced
Windowed
Type of housing
Shelter
Apartment
House
Shack
Time since stroke (months)
Time in rehabilitation (months)
Time of initiating rehabilitation after stroke
(months)
Classification of stroke
Ischemic
Hemorrhagic
Number of stroke
Type of sequelae
Motor
Motor and speech
Pacient with caregiver
Yes
No
Level of dependency
No dependency
Parcial dependency
Total dependency
Type of relationship to caregiver
Wife
Husband
Child
Others
No cargiver
n(%)
Dimension
82(59.0)
57(41.0)
59.4±11.0
38(27.4)
82(59.0)
12(8.6)
7(5.0)
16(11.5)
94(67.6)
29(20.9)
3(1-14)
82(59.0)
14(10.1)
16(11.5)
27(19.4)
3(2.2)
7(5.0)
127(91.4)
2(1.4)
21(3-316)
12(4-112)
3(1-036)
116(83.5)
23(16.5)
1(1-4)
74(53.2)
65(46.8)
Acta Paul Enferm. 2013; 26(2):205-12.
Mean (± SD)
SF-36
Functional capacity
11.4±20.0
Physical aspects
2.9±12.8
Pain
72.4±26.8
General state of health
44.6±16.1
Vitality
58.0±28.4
Social aspects
39.7±32.8
Economics aspects
2.6±12.1
Mental health
59.6±25.6
SSQOL
Personal care
15.9±5.6
Vision
12.4±3.2
Language
18.9±5.5
Mobility
17.7±7.0
Work
5.7±2.8
Upper limb function
13.1±6.3
Mode of thinking
9.2±4.1
Behavior
7.2±3.8
Mood
17.0±6.3
Family relationship
6.5±3.4
Social relationship
7.7±4.2
Energy
8.1±4.6
SSQOL total
139.7±38.4
Barthel Index
135(97.1)
4(2.9)
8(5.8)
93(66.9)
38(27.3)
58(41.7)
22(15.8)
13(9.4)
42(30.4)
4(2.9)
Legend: Values expressed in Numbers (%), Mean (± Standard Deviation) or
Median (Range)
208
Table 2. Scores of the SF-36, SSQOL, Barthel Index and Beck
Depression Inventory in patients in rehabilitation after stroke
Severe dependency
19(13.7)
Major dependency
16(11.5)
Moderate dependency
34(24.4)
Minor dependency
70(50.4)
Beck Depression Inventory
Without depressive synptoms
70(50.3)
Dysphoric symptoms
40(28.8)
Depressive symptoms evident
29(20.9)
Legend: Values Expressed in Mean ± Standard Deviation; SF-36 – Medical
Outcome Study Short-Form 36 - Item Health Survey; SSQOL - Stroke Specific
Quality of Life Scale
Table 3. Linear correlation between dimension of the SSQOl and SF-36, Barthel Index and Beck Depression Inventory in patients with
stroke, in rehabilitation
SF36
SSQOL
BI
BDI
0.16
077
-0.31
0.27
0.11
-0.26
FC
PA
P
GHS
V
SA
EA
MH
Personal care
0.55
0.26
0.15
0.25
0.33
0.61
0.28
Vision
0.14
0.14
0.15
0.13
0.20
0.22
0.11
Language
0.24
0.19
0.17
0.22
0.37
0.31
0.13
0.28
0.17
-0.27
Mobility
0.65
0.35
0.27
0.37
0.39
0.60
0.29
0.23
0.79
-0.37
Work
0.64
0.40
0.14
0.28
0.39
0.52
0.43
0.25
0.57
-0.36
UL function
0.55
0.27
0.20
0.35
0.35
0.49
0.26
0.19
0.60
-0.34
Mode of thinking
0.22
0.27
0.24
0.34
0.47
0.35
0.22
0.43
0.18
-0.47
Behavior
0.05
0.20
0.20
0.16
0.34
0.19
0.10
0.55
0.01
-0.43
Mood
0.29
0.26
0.26
0.34
0.56
0.40
0.19
0.54
0.23
-0.68
Family relationship
0.43
0.29
0.30
0.42
0.47
0.56
0.23
0.43
0.42
-0.59
Social relationship
0.42
0.37
0.22
0.33
0.40
0.51
0.32
0.34
0.36
-0.50
Energy
0.28
0.28
0.30
0.36
0.59
0.29
0.17
0.52
0.23
-0.54
SSQOL total
0.58
0.41
0.33
0.45
0.61
0.65
0.34
0.51
0.60
-0.64
Legend: SSQOL - Stroke Specific Quality of Life Scale; SF-36 - Medical Outcome Study 36-Item Short-Form Health Survey; BI – Barthel Index; BDI – Beck Depression
Inventory; FC – Functional Capacity; PA – Physical Aspects; P – Pain; GHS – General Health State; V – Vitality; SA – Social Aspects; EA – Emotional Aspects ; MH –
Mental Health; UL – Upper Limb
Table 4. Linear regression analysis between the total score of the SSQOL and significant variables of patients with stroke, in
rehabilitation
Coefficient
p-value
Constant
245.0
< 0.001
Level of dependence on caregiver
-34.8
< 0.001
Number of stroke
-10.8
< 0.001
Elementary school
19.6
< 0.001
Middle school
23.2
< 0.025
Female gender
-11.0
< 0.051
Individuals dependent on income
-2.8
< 0.053
Legend: r = 0.362
2
Discussion
The inexistence of research about the theme in the
northeast region of the country limited comparisons with the findings of this study. The state of
Alagoas presented poor health indicators and was
marked by social inequality, along with high indexes of functional incapacity, primarily among
the elderly.
The evaluation of QoL, in individuals with various pathologies, has frequently been studied in the
area of health, since the struggle and achievements
attained by increased survival have not yet been ca-
pable of satisfactorily resolving the maintainance of
its quality.
One of the events that can substantially compromise the life of individuals and the satisfaction
of living is the occurrence of a stroke, because it
presents a potential limitation in all physical as well
as emotional aspects.
The occurrence of a stroke predominantly impacts individuals of the male gender, which also occurred in this study, however when affected, women
presented a lower QoL, possibly due to the functional impairments present that limited their domestic activities.(8,15,16)
Acta Paul Enferm. 2013; 26(2):205-12.
209
This type of pathology affects for the most part,
black individuals with an average age greater than
65 years. In the current study, the incidence was
higher in people with brown skin and with an average age lower than that reported in the literature,
59.4 years, which may reflect the population characteristics of the study location and the inclusion of
younger people.(17)
Low educational level has been linked to the high
incidence of stroke, especially when combined with
socioeconomic and cultural factors and difficulty of
access to information, in addition to impairing the
awareness of health care, treatment adherence and
maintenance of lifestyle, while higher education
points to increased survival, better control of risk
factors for cardiovascular disease and greater ability
to return to work. In this study, 86.4% of patients
did not surpass primary school and 79.1% had income below the poverty level, corroborating the associations made earlier.(3,5,18,19)
The incidence of ischemic disease in question,
varies between 62.2% and 85.0%, consistent with
our findings (83.5%), while the survival rate is related to age, health service used, type and recurrence of
stroke, resulting disability, and associated diseases.(18)
There is a need for family involvement in the
disease process, which may account for the high
prevalence of patients who had a caregiver in this
study, 97%.(16)
The completion of rehabilitation activities is
essential for successful treatment after a stroke. In
this study the majority of patients performed two to
three rehabilitation therapies, twice per week. The
type of rehabilitation therapy most commonly used
was physiotherapy (86.3%). Another study found
a higher percentage of patients who performed
physiotherapy, with a frequency of up to five times
weekly, and good results.(20)
The analyzed by means of some dimensions or
domains that were part of the context of the human
being was affected and generally tended to be compromised in the presence of chronic diseases and
acute diseases and their consequences. In this study
the most compromised domains, according to the
SF-36, were: functional capacity, physical aspects,
general state of health, social aspects and emotional
210
Acta Paul Enferm. 2013; 26(2):205-12.
aspects. Studies conducted with the same type of
patients and questionnaires, revealed that all of the
scores were below 50, before the initiation of activities of rehabilitation and became improved after
these activities. The compromise of these dimensions generated negative consequences for the evolution of the state of health of the patients.(3,8,15,21)
According to the SSQOL, the specific domains
most affected in the study, which are those that
could be triggered in the presence of the disease
or its consequences, were: mobility, work, upper
limb function, behavior, family and social relationships, and energy. Other authors also encountered
scores below 40 in the domains: energy and work,
upper limb function and social relationship, and
scores below 60 in energy, mobility, social relationship, upper limb function and work, and behavior,
demonstrating that the consequences directly related to stroke are numerous and cause an impact of
significant proportions.(8,10, 20,22)
Functional status is identified as one of the determining areas of the of patients, so the utiliization of strategies to improve physical function is a
useful differential capable of positively improving
life after stroke. However, the strategies mentioned
directly depend on social support or the lack thereof. In some aspects of this study, this could partially
explain the low of the patients analyzed.(20)
The scores of the family relationship proved low,
which could reflect aspects of the disease that caused
caregiver role strain and patient dissatisfaction in relation to the care received from the family. Another
researcher showed that good social support and quality family assistance maintained, and in some cases
even improved, the of the patients.(20,23)
The presence of sequelae after stroke, generated
dependence on the part of the patients for the performance of activities of daily living. In this study,
49.6% of patients had moderate to severe dependency, consistent with findings in the literature
ranging between 31% and 62%.(20)
Psychiatric disorders are identified as determinant factors of the disabilities in patients after stroke,
and depression is the most prevalent and is associated
with a poorer prognosis, due to the significant compromise of motor and cognitive rehabilitation.(24)
Functional and cognitive disorders, previous
history of depression, previous stroke and their
neuroanatomical characteristics, a precarious social support network and severe disability are
risk factors associated with the occurrence of depression. Some authors pointed to consequences
of depression such as prolonged hospitalization,
greater functional and cognitive impairment, limitation in performing daily activities, reduction
of survival and lack of functional response during
rehabilitation.(25,26) In the present study, 49.7%
of the patients presented evident dysphoric or depressive symptoms. In other studies a percentage
of patients with depressive symptoms was 40% after the event, 23% in the third month and 18%
in the sixth month, and during the rehabilitation
and incidence of depression was 16.6%. With
the presence of depression and dependency on a
caregiver for completing activities of daily living,
a significant decrease in all of the SF-36 domains
occurred.(5,27,28)
The patients of this study that depended on
caregivers for activities of daily living presented lower QoL in the specific domains of SSQOL. A linear
correlation of the total SSQOL score and SF-36,
Barthel Index and the Beck Depression Inventory
showed a moderate to strong level of correlation.
Another study encountered correlation values of
SSQOL of 0.85, 0.79 and 0.68, respectively.(17)
This study showed a strong association between
the Barthel Index, and two domains of the SSQOL,
personal care (0.77) and mobility (0.79). A multiple regression analysis between the total score of the
SSQOL and the variables, degree of dependence on
the caregiver, number of stroke, elementary/middle
school, female gender and number of people who
depended on income identifed a r2 = 0.362. The
r2 between the Beck Depression Inventory and the
sociodemographic, economic, clinical and the total
SSQOL was 0.729.
The degree of dependency on the caregiver for
the performance of activities of daily living, the
number of stroke and the presence of signs of depression were the variables largely responsible for
altering the specific , measured by SSQOL, of patients in this study.
The presence of caregivers is considered essential
for the treatment of patients who have had a stroke,
however, their intervention needs to be positive in
order to influence the recovery and rehabilitation of
patients, by means of incentives, neither underestimating nor overestimating the patient’s capacity.(29)
The study about in patients with stroke showed
that variables such as physical function deficit, presence of depression or its symptoms, being of female
gender, and advanced age could negatively influence . Women with stroke had lower , especially, in
the mental health domain, regardless of age, severity
and etiology of stroke, and presence of other comorbidities.(15,30)
Conclusion
The general and specific of patients with stroke, in
rehabilitation, is diminished and correlated to the
limitations in performing activities of daily living.
The presence of dysphoric or depressive symptoms,
major degree of dependence on the caregiver, higher
number of stroke, lower level of education, female
gender, and the higher number of people dependent
on income interfered negatively in the specific .
Collaborations
Rangel ESS; Belasco AGS and Diccini S declare that
they contributed to the concept and design of the project, analysis and interpretation of the data; drafting of
the article, critical revision related to intellectual content and approved the final version to be published.
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