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Official Organization for Scientific Dissemination of the Escola Paulista de Enfermagem, Universidade Federal de São Paulo Acta Paulista de Enfermagem/ Escola Paulista de Enfermagem/ Universidade Federal de São Paulo Address: Napoleão de Barros street, 754, Vila Clementino, São Paulo, SP, Brazil. Zip Code: 04024-002 Acta Paul Enferm. volume 27, issue(3), May/June 2014 ISSN: 1982-0194 (electronic version) Frequency: Bimonthly Phone: +55 11 5576.4430 Extensions 2589/2590 E-mail: [email protected] Home Page: http://www.unifesp.br/acta/ Facebook: facebook.com/ActaPaulEnferm Twitter: @ActaPaulEnferm Tumblr: actapaulenferm.tumblr.com Editorial Council Editor-in-Chief Sonia Maria Oliveira de Barros Acta Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil Technical Editor Edna Terezinha Rother Acta Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil Associate Editors Ana Lucia de Moraes Horta, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil Ariane Ferreira Machado Avelar, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil Bartira de Aguiar Roza, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil Elena Bohomol, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil Elisabeth Niglio de Figueiredo, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil Erika de Sá Vieira Abuchaim, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil Maria Magda Ferreira Gomes Balieiro, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil Rosely Erlach Goldman, Escola Paulista de Enfermagem - Unifesp, São Paulo-SP, Brazil Tracy Heather Herdman, University of Wisconsin, CEO & Executive Director NANDA International, Green Bay-Wisconsin, USA Editorial Board National Alacoque Lorenzini Erdmann, Universidade Federal de Santa Catarina-UFSC, Florianópolis-SC, Brazil Ana Cristina Freitas de Vilhena Abrão, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil Cibele Andrucioli de Matos Pimenta, Escola de Enfermagem da Universidade de São Paulo-EE/USP, São Paulo-SP, Brazil Circéa Amália Ribeiro, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil Conceição Vieira da Silva-Ohara, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil Elucir Gir, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil Emília Campos de Carvalho, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil Isabel Amélia Costa Mendes, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil Isabel Cristina Kowal Olm Cunha, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil Ivone Evangelista Cabral, Escola de Enfermagem Anna Nery- EEAN/UFRJ, Rio de Janeiro-RJ, Brazil Janine Schirmer, Universidade Federal de São Paulo-USP, São Paulo-SP, Brazil Josete Luzia Leite, Escola de Enfermagem Anna Nery - EEAN/UFRJ, Rio de Janeiro-RJ, Brazil Lorita Marlena Freitag Pagliuca, Universidade Federal do Ceará-UFC, Fortaleza-CE, Brazil Lúcia Hisako Takase Gonçalves, Universidade Federal de Santa Catarina-UFSC, Florianópolis-SC, Brazil Margareth Ângelo, Universidade de São Paulo-USP, São Paulo-SP, Brazil Margarita Antônia Villar Luís, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil Maria Antonieta Rubio Tyrrel, Escola de Enfermagem Anna Nery- EEAN/UFRJ, Rio de Janeiro-RJ, Brazil Maria Gaby Rivero Gutiérrez, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil Maria Helena Costa Amorim, Universidade Federal do Espírito Santo-UFES, Vitória-ES, Brazil Maria Helena Lenardt, Universidade Federal do Paraná-UFP, Curitiba-PR, Brazil Maria Helena Palucci Marziale, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil Maria Júlia Paes da Silva, Universidade de São Paulo-USP, São Paulo-SP, Brazil Maria Márcia Bachion, Universidade Federal de Goiás-UFG, Goiânia-GO, Brazil Maria Miriam Lima da Nóbrega, Universidade Federal da Paraíba-UFPB, João Pessoa-PB, Brazil Mariana Fernandes de Souza, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil I Mavilde da Luz Gonçalves Pedreira, Universidade Federal de São Paulo-Unifesp, São Paulo-SP, Brazil Paulina Kurcgant, Universidade de São Paulo-USP, São Paulo-SP, Brazil Raquel Rapone Gaidzinski, Universidade de São Paulo-USP, São Paulo-SP, Brazil Rosalina Aparecida Partezani Rodrigues, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil Silvia Helena De Bortoli Cassiani, Universidade de São Paulo-USP, Ribeirão Preto-SP, Brazil Telma Ribeiro Garcia, Universidade Federal da Paraíba-UFPB, João Pessoa-PB, Brazil Valéria Lerch Garcia, Universidade Federal do Rio Grande-UFRGS, Rio Grande-RS, Brazil International Barbara Bates, University of Pennsylvania School of Nursing - Philadelphia, Pennsylvania, USA Donna K. 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III Editorial T ransplantation has celebrated major achievements over the past decades due to more refined surgical techniques, more potent and targeted immunosuppressive drugs, and better treatments against infection. Survival rates after solid organ transplantation have improved significantly although this has been primarily achieved by a decrease in organ attrition in the first year post-transplant. Improving long-term survival beyond one year post-transplant remains the major challenge of transplant clinicians and researchers. The hight attrition rates in the long-term after transplantation is lead by existing pre-transplant and newly-developed comorbidities post-transplant, due to not only the side effects of immunosuppressants but also to unhealthy life style (e.g., smoking, sedentarism, unhealthy diet). Furthermore, medication non-adherence is associated with increased risk in late acute rejections, graft loss, and possibly death, besides the disease burden in this population. In order to improve long-term outcomes after solid organ transplantation, investment in new models of care, such as the Chronic Care Model (CCM), has been proposed. The CCM is based on the principles of chronic illness management (CIM), addressing the needs of solid organ transplant recipients regarding continuity of care and support for patient self-management. The CCM contrasts with the prevailing acute care model. Nurses play a crucial role in CCM, especially in the self-management support and providing continuity of care across institutional boundaries. One Canadian quase-experimental study showed that implementing the CCM in transplant patient’s follow-up improved clinical and healthcare utilization outcomes. In order to better understand the practice patterns regarding CIM worldwide in transplantation, the Building research initiative group: chronic illness management and adherence in transplantation (BRIGHT) study was launched. This study covers 4 continents, 11 countries and 38 heart transplant centers. This study will allow describing and benchmarking transplant patient’s health behaviors as well as practice patterns of CIM in transplantation and provide transplant clinicians with essential information on how to improve their transplant practices with the goal to improve long-term outcomes post-transplant. Sabina De Geest PhD, RN, FAAN, FEANS, FRCN University of Basel, Switzerland & KU Leuven, Belgium Lut Berben PhD, RN University of Basel, Switzerland & KU Leuven, Belgium DOI: http://dx.doi.org/10.1590/1982-0194201400033 IV Contents Original Articles Nursing faculty’s opinion on effectiveness of nonverbal communication in the classroom Opinião de docentes de enfermagem sobre a efetividade da comunicação não verbal durante a aula Rosely Kalil de Freitas Castro Carrari de Amorim, Maria Júlia Paes da Silva�� 194 Prevalence of common mental disorders in primary health care Prevalência de transtorno mental comum na atenção primária Roselma Lucchese, Kamilla de Sousa, Sarah do Prado Bonfin, Ivânia Vera, Fabiana Ribeiro Santana�� 200 Prevalence of depressive symptoms and associated factors among institutionalized elderly Prevalência de sintomatologia depressiva e fatores associados entre idosos institucionalizados Márcia Carréra Campos Leal, João Luis Alves Apóstolo, Aída Maria de Oliveira Cruz Mendes, Ana Paula de Oliveira Marques�� 208 Ethical conflicts experienced by nurses during the organ donation process Conflitos éticos vivenciados por enfermeiros no processo de doação de órgãos Mara Nogueira de Araújo, Maria Cristina Komatsu Braga Massarollo�� 215 Translation, adaptation and validation of a self-care scale for type 2 diabetes patients using insulin Tradução, adaptação e validação de uma escala para o autocuidado de portadores de diabetes mellitus tipo 2 em uso de insulina Thaís Santos Guerra Stacciarini, Ana Emilia Pace�� 221 Quality of life related to the health of chronic renal failure patients on dialysis Qualidade de vida relacionada à saúde de pacientes renais crônicos em diálise Jéssica Maria Lopes, Raiana Lídice Mor Fukushima, Keika Inouye, Sofia Cristina Iost Pavarini, Fabiana de Souza Orlandi��230 Social and clinical factors causing mobility limitations in the elderly Fatores sociais e clínicos que causam limitação da mobilidade de idosos Jorge Wilker Bezerra Clares, Maria Célia de Freitas, Cíntia Lira Borges�� 237 Care practices for patient safety in an intensive care unit Práticas assistenciais para segurança do paciente em unidade de terapia intensiva Taís Pagliuco Barbosa, Graziella Artuzi Arantes de Oliveira, Mariana Neves de Araujo Lopes, Nádia Antonia Aparecida Poletti, Lúcia Marinilza Beccaria�� 243 Analysis of blood pressure records at post-anesthesia recovery room Análise dos registros da pressão arterial na sala de recuperação pós-anestésica Aline Aparecida Souza Cecílio, Aparecida de Cássia Giani Peniche, Débora Cristina Silva Popov�� 249 Difficulties faced by parents of children with gastroesophageal reflux disease Dificuldades enfrentadas pelos pais de crianças com doença do refluxo gastroesofágico Jacqueline Andréia Bernardes Leão Cordeiro, Sacha Martins Gualberto, Virginia Visconde Brasil, Grazielle Borges de Oliveira, Antonio Márcio Teodoro Cordeiro Silva�� 255 Prevalence of burnout syndrome among resident nurses Ocorrência da síndrome de Burnout em enfermeiros residentes Kelly Fernanda Assis Tavares, Norma Valéria Dantas de Oliveira Souza, Lolita Dopico da Silva, Celia Caldeira Fonseca Kestenberg�� 260 V Compliance with outpatient clinical treatment of hypertension Adesão ao tratamento clínico ambulatorial da hipertensão arterial sistêmica Aurelina Gomes e Martins, Suzel Regina Ribeiro Chavaglia, Rosali Isabel Barduchi Ohl, Igor Monteiro Lima Martins, Mônica Antar Gamba�� 266 Nasal colonization by Staphylococcus sp. in inpatients Colonização nasal por Staphylococcus sp. em pacientes internados Gilmara Celli Maia de Almeida, Nara Grazieli Martins Lima, Marquiony Marques dos Santos, Maria Celeste Nunes de Melo, Kenio Costa de Lima�� 273 Occurrence of occupational accidents involving potentially contaminated biological material among nurses Ocorrência de acidentes de trabalho com material biológico potencialmente contaminado em enfermeiros Marília Duarte Valim, Maria Helena Palucci Marziale, Miyeko Hayashida, Miguel Richart-Martínez�� 280 Changes in Quality of Life after kidney transplantation and related factors Mudanças na qualidade de vida após transplante renal e fatores relacionados Ana Elza Oliveira de Mendonça, Gilson de Vasconcelos Torres, Marina de Góes Salvetti, Joao Carlos Alchieri, Isabelle Katherinne Fernandes Costa�� 287 VI Original Article Nursing faculty’s opinion on effectiveness of non-verbal communication in the classroom Opinião de docentes de enfermagem sobre a efetividade da comunicação não verbal durante a aula Rosely Kalil de Freitas Castro Carrari de Amorim1 Maria Júlia Paes da Silva1 Keywords Communication; Nonverbal communication; Education, nursing; Faculty, education; Teaching/methods Descritores Comunicação; Comunicação não verbal; Educação em enfermagem; Docentes de Enfermagem; Ensino/ métodos Submitted March 13, 2014 Accepted May 26, 2014 Corresponding author Rosely Kalil de Freitas Castro Carrari de Amorim Doutor Enéas de Carvalho Aguiar Avenue, 419, São Paulo, SP, Brazil. Zip Code: 05403-000 [email protected] DOI http://dx.doi.org/10.1590/19820194201400034 194 Acta Paul Enferm. 2014; 27(3):194-9. Abstract Objective: To determine the opinion of nursing faculty and a researcher on the effectiveness of non-verbal communication in the classroom. Methods: This descriptive study included 11 nursing professors filmed for 220 minutes. Fourteen aspects of non-verbal communication were evaluated. Opinions about the effectiveness of non-verbal communication are expressed as simple frequencies. Results: Professors identified 71.43% of postures (as coherent, good, effective, and adequate), 62.5% of facial expressions (efficient, positive, and reinforcing/following the speech), 83.33% of voice rhythms (effective, good, and adequate speed), 61.11% of physical energy levels (good rhythm, active, attentive, effective, adequate, and alert), and 78.95% of body postures (kept moving, standing, remaining on feet, using hand movements to illustrate points, attention focused on students, position close to students’ desks). A less frequent inefficient non-verbal communication was seen among. Conclusion: Nursing professors’ opinions on non-verbal communication in the classroom were general and non-specific, indicating inadequate application of non-verbal communication. Professors identified inefficient non-verbal communication behavior less often than did one of the current researchers. Resumo Objetivo: Conhecer a opinião de docentes de enfermagem e da pesquisadora sobre a efetividade da comunicação não verbal durante as aulas. Métodos: Estudo descritivo no qual foram incluídos 11 docentes de enfermagem em 220 minutos de filmagem. Foram avaliados 14 aspectos da comunicação não verbal. A opinião sobre a efetividade da comunicação não verbal foi apresentada em frequência simples. Resultados: Os docentes identificaram: 71,43% da postura (coerente, boa, efetiva e adequada); 62,5% das expressões faciais (eficientes, positivas e reforçando/acompanhando a fala); 83,33% do ritmo da voz (efetivo, bom e com velocidade adequada); 61,11% do nível de energia − física (ritmo bom, ativo, atento, efetivo, adequado e alerta); 78,95% da postura corporal (manter-se em movimento, estar ereto, de pé, usar gestos ilustradores, voltar-se para os alunos, estar próximo dos alunos das carteiras da frente). Além disso, houve uma menor frequência de comunicação não verbal ineficaz entre os docentes. Conclusão: A opinião dos docentes de enfermagem sobre a comunicação não verbal durante as aulas é geral e inespecífica, indicando inadequação na aplicação desta comunicação. Os docentes identificaram comportamentos comunicativos não verbais ineficazes em menor freqüência do que a pesquisadora. Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, Brazil. Conflicts of interest: none to report. 1 Amorim RK, Silva MJ Introduction Technologic advances have been gaining prominence everywhere, including the classroom environment. The use of computers, smartphones, and tablets by students presents undeniable interference. These devices divert students’ attention from the professor and change the professor-student relationship. This reflects how both professor and students have been interacting in this context. Study of the professor-student relationship deserves emphasis to establish positive affective ties that enable productive information and knowledge exchange in this new reality. To ensure an adequate relationship, nursing professors should understand methods of communication, including non-verbal communication. Communication involves an interpersonal dimension that characterizes relationships and should be understood to be effectively used. Educators mention that effective professors must model behavior and qualities that are in consonance with the lesson taught, be positive and hopeful, how to listen and talk, and show concern for students’ well-being. These abilities can be developed, especially through effective non-verbal communication, which is an instrument to achieve this result.(1) Humans differ from other animals by their ability to perform actions consciously (i.e., to act intentionally and not by instinct or by conditioned reflex); this is called praxis or work. Work is also an interventional instrument and a measure of human appropriation of the world.(2) For this reason, if a professor’s role is to build knowledge for students through information transmission and exchange, the professor must communicate appropriately using conscious transformative knowledge and non-verbal communication. This will provide the professor the skills to develop an activity that is in consonance with his or her intentions as a learning mediator. There is a schematic chart of non-verbal communication models that can be adapted to the professor-student relationship. This chart shows how the use of non-verbal is effective in interpersonal interactions. Non-verbal communicative behavior is separated into effective/efficacious use and inefficacious use with regard to the following: physical posture, eye contact, the use of furniture, clothing, facial expressions, and interpersonal distance. The behaviors considered effective/efficacious are those that encourage the other person to talk because he or she feels accepted and respected; the inefficacious behaviors are those that weaken the conversation.(3) Studies on nursing communication that approach the teaching-learning process point out that the mediator aspect is the importance of conscience that the professor must have on his/ her communicative role.(4-6) The difficulty of codifying students’ non-verbal communication behavior was noted in a study with nursing faculty that aimed to verify the existence of differences in professors’ perceptions of students’ feelings before and after an explanatory presentation.(6) The study found that professors’ perceptions with regard to identifying feelings improved after the explanation, when their attention was directed toward non-verbal communication.(6) Because of the interference of technologic advances and new teaching-learning techniques in the classroom, studies on interpersonal communication involving professor-student should be redone, reviewed, and discussed in this new context. This especially pertains to studies on relative changes in non-verbal communication, an interpersonal dimension that qualifies the relationships. This study sought to determine the opinions of nursing faculty and a researcher’s on the effectiveness of non-verbal communication in the classroom. Methods This descriptive study was carried out at private university in the city of São Paulo, located in the southeast region of Brazil. We included 11 nursing professors who taught in at least two disciplines in the nursing undergraduate program. Communication is a dynamic process. For this reason, we used video recording in the teaching-learning context in the classroom environment. Acta Paul Enferm. 2014; 27(3):194-9. 195 Nursing faculty’s opinion on effectiveness of non-verbal communication in the classroom The filming started 30 minutes after the start of class and lasted for 20 minutes without interruptions. The camera was placed at medium body frame because most non-verbal communication occurs in this perspective. Because filming focused on the professor, the camera was positioned so that only the professor was captured. Only the backs of students were filmed. All students were informed about the reason of the filming and were told they would not appear in the video because the focus was only the professor. In the second step, a day was scheduled with each professor to watch the video with the researcher. Before the viewing began, the researcher explained to the professor how the data collection instrument was composed and how it must completed. The professor was also told that the he/she was authorized to see the video twice, if necessary. On the data collection form professors described their perceptions after watching the video, pointing out efficient and inefficient examples of the 14 aspects of non-verbal communication assessed (posture, eye contact, furniture, clothes, facial expression, mannerism, rhythm and volume of voice, level of physical energy, interpersonal distance, touch, head movement, body posture, and paraverbal characteristics). The researcher also watched each video by herself and completed the instrument. Data collected from professors and from the researcher were analyzed based on the adopted theoretical reference. Results were expressed using simple frequencies of professors who were able to identify the times they expressed non-verbal signs in the classroom for each aspect. Development of this study followed national and international ethical and legal aspects of research on human subjects. Results Eleven nursing faculty were filmed and interviewed. The participants’ mean time as a professor was 18 years (range, 7 to 29 years). 196 Acta Paul Enferm. 2014; 27(3):194-9. All professors were filmed in the classroom, with student desks organized into rows. The classroom also contained a support table for the teacher that was placed closed to a white board, generally on the side opposite the entrance door. The white board was used to project slides from a monitor connected to the professor’s personal computer. Some professors used the white board to make notes while explaining the subjects addressed during the class. In the institution where this study was conducted, the use of a white coat by the professor was optional. Table 1. Nursing faculty and the researcher’s opinion Researcher’s opinion Non-verbal communication Faculty’s opinion Effective use Inefficient use Effective use Inefficient use Posture 14 10 10 3 Eye contact 20 4 11 5 Furniture 12 10 7 7 Clothes 7 8 11 0 Facial expression 16 10 10 3 Mannerism 0* 39 4* 9 Volume of voice 19 3 10 1 Tone of voice 12 10 10 3 Level of energy 18 5 11 1 Personal distance 27 12 9 5 Touch 20 2 6** 3 Head movement 22 2 11 1 Body posture 19 24 15 5 Paraverbal 20 13 10 5 *Os maneirismos não devem existir, portanto, o eficaz é zero de maneirismos, embora quatro docentes tenham achado seus maneirismos efetivos; ** um docente tocou uma aluna, considerando o toque efetivo; outros cinco docentes, que não fizeram uso do toque com os alunos, julgaram a ausência do toque efetiva, por entenderem que o mesmo não caberia naquela situação Table 1 shows the professors’ and the researcher’s opinions regarding the efficient and inefficient use of non-verbal communication. During the 20 minutes of filming observed by the researcher for each non-verbal dimension, the absolute number of effective or ineffective instances she perceived computed and considered as 100%. For example, for posture, there were 14 instances of effective use and 10 instances of ineffective use of non-verbal communication, which represent the sum of the videos of all professors. The dimensions perceived more by the professors than by researcher concerned the effectiveness of non-verbal signs produced (over 60%) and how professors described each dimension (noted in parentheses). Professors identified 71.43% of Amorim RK, Silva MJ postures (coherent, good, effective and adequate), 62.5% of facial expressions (efficient, positive and reinforcing/following the speech), 83.33% of voice rhythms (effective, good and adequate speed), 61.11% of physical energy levels (good rhythm, active, attentive, effective, adequate, and alert), 78.95% of body postures (kept moving, standing, remained on feet, using hand movements to illustrate points, attention focused on students, position close to students’ desks). All professors considered clothes to be standard and adequate for the classroom, with pleasing and neutral colors; however, the researcher considered inappropriate that some professors had their white coat opened. The majority of professors, 54.5%, did not know the meaning of the term “mannerism.” Professors perceived fewer inefficient non-verbal communication behavior than did the researcher (Table 1). They did not perceive details that could harm the professor-student relationship, such as those found in posture, organization of furniture, mannerisms, rhythm of voice, interpersonal distance, absence of touch (even in situations where it seemed appropriate), head movement, body posture, and paraverbal aspects. Discussion A limitation of this study was its descriptive design, which did not permit the researchers to establish relations of cause and effect, the subjective characteristics of non-verbal communication, the objective of the study, and the comparison between professors and the researcher. Our results show the importance of non-verbal communication in the learning-teaching environment. Adequate codification of non-verbal communication requires capacitation, training, conscience, and constant attention during the observation period; several non-verbal sings are transmitted at the same time as verbalization mainly. These can be considered microexpressions that last 1/12 to 1/5 seconds and represent, in a non-verbal form, the speakers’ true feelings.(7) Most people cannot, without training, perceive microexpressions during a conversation because these are mixed with words, tone of voice, and gestures.(7) This difficulty also stems from the fact that people tend to think beforehand of what they will say unless they only observe and listen. We verified that after the initial 5 minutes of adaptations and adjustments, some professors retained their ineffective communicative behaviors throughout the rest of the filming. Such behaviors included distance and posture in relation to students, tense and angry facial expressions, mannerisms, low voice, accelerated rhythm of voice, keeping a distance from the students, positioning of the head at variance with voice projection, tense body posture, and repetitive paraverbal characteristics, with word repetitions at the end of the discourse. Mannerisms that were seen several times in all films deserve to be highlighted for the meaning they could transmit in addition to those already reported (tension, nervousness, and anxiety) and for the distraction they can generate. In general, the gesture of running hands through one’s hair is codified as a sign used by women while dating or flirting;(8) however, in the classroom context it is more related to concern about physical appearance. In this particular instance, it can also be considered in relation to concern about appearance to those who will see the video. A body posture that involves walking with the chin up and hands crossed behind the back indicates superiority and self-confidence; keeping hands in pockets may indicate that something is being hidden; scratching eyebrows, face, nose, and mouth are signs related to filtering of information or lying about what has been said, saw, or heard.(9) Audiovisual resources have an important role in interpersonal distance and body posture. Some professors tend to stand on one side of the room, as close as possible to the audiovisual resources, or they tend to be positioned laterally or back toward the students for long periods of times, reading slides. The function of audiovisual recourses is to illustrate, clarify, and simplify presentations and, during their use, eye contact must be kept with the audience/ Acta Paul Enferm. 2014; 27(3):194-9. 197 Nursing faculty’s opinion on effectiveness of non-verbal communication in the classroom students. The professor/speaker should avoid, as much as possible, reading the slides or speaking while looking at the audiovisual resources.(10) The head movements used most were the sign of a positive response (inclining the head forward indicating “yes” or affirmation) and the sign of negation (moving the head from one side to another, indicating “no”).(9) In other cultures, such as in Bulgaria, some parts of the Greece, Yugoslavia, Turkey, Iran, and Bengal, these movements have the opposite meaning (i.e., moving the head up and down is a sign for “no,” and moving the head side to side is a sign for “yes”).(11) In filming of the professors, almost all used their head to indicate consenting, which stimulated the students’ participation (positive movement). During interactions, it is important to note if the speaker is affirming something verbally but is making a different movement with the head, indicating, for example, a hidden objection.(8) Furniture organization in the classroom did not change, even in the classrooms that enabled certain mobility and had few students (maximum of eight), in order to make the teaching-learning environment more welcoming, inclusive, and productive. Hence, learning can be compromised in some classrooms even with professors with an audible voice because there is too much external noise. With few exceptions in which professors touched students, professors kept a distance that varied between personal distance (45 to 125 centimeters in relation to the students in the first row) and social distance (124 to 360 centimeters in relation to intermediary rows).(12) In large classroom and those with more distance between rows, professors kept a public distance, which necessitated using a microphone to amplify their voice. This relationship could be different if professors circulate more in the classroom, keeping a personal distance among more students; show more accessibility and availability in the learning-teaching process; facilitate contact, interaction and flow of communication needed to comprehend the content. Such improvements would also help the students apply communicative learning with patients, families, and multidisciplinary teams after they leave the classroom. 198 Acta Paul Enferm. 2014; 27(3):194-9. Without a doubt, the professor is the person who inspires and encourages students as they develop their communicative ability. In developing this communicative ability, it is important that contact with professor is a positive experience; this is mainly achieved via the proximity to student in the classroom. Professors mention that their incomprehension of the generation, unfolding of values and lack of knowledge related to those they interact with is a large obstacle for an autonomous pedagogical relationship.(2) For professors for whom pedagogical autonomous relationships occur easily, the knowledge domain and applicability of non-verbal communication in classroom are fundamental instruments. The study of non-verbal communication requires knowledge, training, and observation of others, but mainly self-knowledge.(5,13) The latter is developed in several forms: body conscience, thoughts, intentions and emotions, aligned with objectives, interior serenity, internal balance, and constant reflection.(13) Conclusion The opinion of nursing faculty regarding non-verbal communication in the classroom is general and unspecified, indicating inadequate application of this communication in the classroom. The professors identified inefficient non-verbal communication behavior less frequently than did the researcher. Acknowledgements We thank the Coordination for the Improvement of Higher Education Personnel (CAPES) for the master’s degree funding given to RoselyKalil de Freitas Castro Carrari de Amorim. Collaborations Amorim RKFCC contributed to the conception of the project and the research and drafting of the manuscript. Silva MJP contributed to conception of the project, critical review to improve the manu- Amorim RK, Silva MJ script intellectual content and final approval of this final version for publication. 6. Sgariboldi AR, Puggina AC, Silva MJ. Professors’ perception of students’ feelings in the classroom: an analysis. Rev Esc Enferm USP. 2011;45(5):1201-7. 7. Edelstein RS, Luten TL, Ekman P, Goodman GS. Detecting lies in children and adults. Law Hum Behav. 2006;30(1):1-10. References 8. Pease A, Pease B. Body language in the workplace. Buderim: QLD Pease International; 2011. 1. Freire P. Pedagogy of freedom: ethics, democracy, and civic courage. New York: Rowman & Littlefield; 2013. 9. Knapp ML, Hall JA. Nonverbal communication in human interaction. Boston: Wadsworth, Cengage Learning; 2010. 2. Cortella MS. A escola e o conhecimento: fundamentos epistemológicos e políticos. 14a ed. São Paulo: Cortez; 2011. 10.Longo A, Tierney C. Presentations Skills for the nurse Educator. J Nurses Staff Dev. 2012;28(1):16-23. 3. Castro RB, Silva MJ. A comunicação não-verbal nas interações enfermeiro-usuário em atendimentos de saúde mental. Rev Latinoam Enferm. 2001;9(1):80-7. 11.Axtell RE. Essential do’s and taboos: the complete guide to international business and leisure travel. New Jersey: John Wiley & Sons; 2007. 4. Bosquetti LS, Braga EM. Communicative reactions of nursing students regarding their first curricular internship period. Rev Esc Enferm USP. 2008;42(4):687-93. 12.Hall ET. Proxemics - a complex cultural language - a citation classic commentary on a system for the notation of proxemic behavior by Hall ET. Current Contents: Arts & Humanities. 1989;19(5):16. 5. Braga EM, Silva MJ. Competent communication: a view of nurse experts in communication. Acta Paul Enferm. 2007;20(4):410-4. 13. Wood P. Secrets of the people whisperer: using the art of communication to enhance your own life, and the lives of others. London: Random House (UK); 2008. Acta Paul Enferm. 2014; 27(3):194-9. 199 Original Article Prevalence of common mental disorders in primary health care Prevalência de transtorno mental comum na atenção primária Roselma Lucchese1 Kamilla de Sousa1 Sarah do Prado Bonfin1 Ivânia Vera1 Fabiana Ribeiro Santana1 Keywords Primary care nursing; Nursing research; Mental health; Mental disorders/ epidemiology; Mental health assistance Descritores Enfermagem de atenção primária; Pesquisa em enfermagem; Saúde mental; Transtornos mentais/ epidemiologia; Assistência à saúde mental Submitted January 16, 2014 Accepted May 29, 2014 Corresponding author Ivânia Vera Av. Doutor Lamartine Pinto de Avelar, 1120, Catalão, GO, Brazil. Zip Code: 75704-020 [email protected] DOI http://dx.doi.org/10.1590/19820194201400035 200 Acta Paul Enferm. 2014; 27(3):200-7. Abstract Objective: To assess the prevalence of common mental disorder and its related factors in primary health care. Methods: Cross-sectional study with 607 individuals in a primary health care service. The instrument of the study was the Self Reporting Questionnaire 20. Results: Out of the interviewed subjects, 31.47% showed greater probability of occurrence of a common mental disorder. The following predictive variables were associated with a lower probability of occurrence of common mental disorder: sex, being single, being a student or a worker with signed labor, having higher education levels and income over four times the minimum wage. The variables associated with a higher probability of occurrence of a common mental disorder were being self-employed, housewife, with children, having lower education level and low income. Conclusion: The prevalence of a common mental disorder was high and the associated factors were: being female, divorced, Asian, aged between 18 and 59, housewife, with children, having four to seven years of education, income up to one minimum age and living in a borrowed or donated house. Resumo Objetivo: Estimar a prevalência de transtorno mental comum e seus fatores associados em serviço de atenção primária. Métodos: Estudo transversal que incluiu 607 indivíduos em serviço de atenção primária. O instrumento de pesquisa foi o questionário Self Report Questionnaire 20. Resultados: Dos sujeitos entrevistados, 31,47% apresentaram maior probabilidade para transtorno mental comum. Foram associadas à menor probabilidade de desenvolvimento do Transtorno Mental Comum as variáveis preditoras: gênero, estado civil solteiro, ocupação estudante e com carteira assinada, maior nível de escolaridade e renda acima de quatro salários mínimos. E, à maior probabilidade de desenvolvimento do Transtorno Mental Comum as variáveis referir ocupação autônoma, do lar, ter filhos, menor escolaridade e baixa renda. Conclusão: A prevalencia de Transtorno Mental Comum foi alta e os fatores associados foram: no gênero feminino, divorciado ou separado, cor da pele amarela, idade de 18 a 59 anos, ocupação do lar, com filhos, com quatro a sete anos de estudo, renda de até um salário mínimo e residindo em moradia emprestada ou doada. Universidade Federal de Goiás, Catalão, GO, Brazil. Conflicts of interest: there are no conflicts of interest to declare. 1 Lucchese R, Sousa K, Bonfin SP, Vera I, Santana FR Introduction Estimates suggest that 14% of the overall load of non-psychotic mental disorders come from neuropsychiatric disorders.(1,2) The chronic and disabling nature of the disease is associated with this figure, which draws the attention to its importance for public health. This situation worsens when the mental disorder is associated with other morbidities, such as increased risk of communicable or non-communicable diseases, and contributes to expected and unexpected injuries.(1) In that sense, the mental illness is followed by a series of developments in biological, cultural, social, economic and political aspects.(3) And among mental disorders, this study analyzed common mental disorder (CMD), as it represents the most prevalent disorder in the world population.(2,4) The common mental disorder, also called non-psychotic mental disorder, is diagnosed when people are mentally ill and present somatic symptoms such as irritation, fatigue, forgetfulness, concentration decrease, anxiety and depression.(2,5) Global projections for 2030 seek to include these disturbances among the most disabling for human beings.(2) In Brazil, the prevalence varies between 28.7 and 50% and is considered by specialists to be high, especially among women and elderly people.(5-8) This information demonstrates the importance of tracking actions for possible cases of common mental disorder within a community, particularly in the primary health care and family health programs.(7) Among the instruments used for its identification is the Self Reporting Questionnaire 20 (SRQ-20), because of its psychometric features in the breakdown of possible cases of common mental disorder within the community, as well as its capacity to identify emotional disorders and needs in mental health.(5,9) The SRQ-20 was validated in Brazil in 1986 and remodeled as a cutoff point for tracking common mental disorder within communities in 2008. Since then, the instrument has been used with the general population, with elderly people and people with diabetes.(5,7-11) However, the estimate of common mental disorder in primary health care deserves further research, as health care, at this level, has the incorporation of mental health practices as one of its challenges, and this achievement will be consolidated after the real picture has been properly analyzed. The objective of this study is to assess the prevalence of common mental disorder and its related factors in primary health care. Methods Sectional, observational and analytical study carried out in a medium-sized municipality in the center-west of Brazil with significant socioeconomic representativeness in the region. A total of 1,440 families are registered in this service, with approximately 4,810 people. Convenience sampling was used. Excluded individuals were: those diagnosed with severe and persistent mental disorder, with cognitive deficit or under the influence of alcohol or other drugs, with non-matching address and individuals who were not located. Data were collected between July 2011 and February 2012. The instrument used for data collection was the Self Reporting Questionnaire (SRQ-20), which is made up of 20 questions related to mental health conditions in the last 30 days. The answers may be “YES” or “NO”, and each “YES” corresponds to one point. The result may vary from 0 (no probability of common mental disorder) to 20 (very high probability of common mental disorder). The cutoff point considered for this study was ≥7 for both genders.(5) The individuals who had scores ≥7 were sent to psychological care in a basic health care unit (UBS, as per its acronym in Portuguese) of the health care program network in the municipality or to a psychosocial care center. Data were entered into Microsoft Excel for Windows® 2003-2007 spreadsheet after a double-check. The analysis of data was performed by frequency and relative frequency distribution, mean, and standard deviation with the Software for Windows® Statistical Package for Social Science for Windows (SPSS) version 15.0.(12) For the univariate analysis, the score ≥7 was considered as outcome (higher probability of having common mental disorder), also considering predictive variables and the sociodemographic. For univariate analysis between the probability of common mental Acta Paul Enferm. 2014; 27(3):200-7. 201 Prevalence of common mental disorders in primary health care disorder and predictive variables, the chi-square test (c)2 or Fischer’s test was performed, with a significance level of 5%. The effect measure used was the prevalence ratio (PR) and the respective confidence intervals (CI95%). Factors were associated with the outcome variable when p was lower than 0.05.(13) The development of the study complied with national and international ethical guidelines for studies involving human beings. Results Study participants were 607 individuals, out of which 31.47% had high probability of having common mental disorder. The lowest SRQ-20 score was zero and the highest was 19 (YES), with a 5.35 mean and 4.00 median (±4.177) for the answer “YES”. Table 1 shows the characteristics of the sample. Table 1. Socioeconomic and demographic characterization Variables n(%) ≥7 SRQ 20 <7 SRQ 20 n(%) n(%) PR CI95% p-value 0.32 (0.20-0.50) 0.000* Gender Male 150(24.7) 18(12) 132(88.0) Female 457(75.3) 173(37.9) 284(62.1) With partner 417(68.7) 137(32.9) 280(67.1) 1.16 (0.89-1.51) 0.275 Single 102(16.8) 22(21.6) 80(78.4) 0.64 (0.44-0.95) 0.018* 0.97 (0.63-1.51) 0.893 1.00 Marital status Widowed 49(8.1) 15(30.6) 34(69.4) Divorced/Separated 39(6.4) 17(43.6) 22(56.4) 1.00 Color skin White 310(51.1) 96(31.0) 214(69.0) 0.97 (0.77-1.22) Black 48(7.9) 15(31.3) 33(68.8) 0.99 (0.64-1.54) 0.787 0.973 Brown 228(37.6) 71(31.1) 157(68.9) 0.98 (0.77-1.25) 0.893 Asian 21(3.5) 9(42.9) 12(57.1) 18 to 59 years 510(84.0) 163(32.0) 347(68.0) ≥60 years 97(16.0) 28(28.9) 69(71.1) 1.00 Age 1.11 (0.79-1.55) 0.547 1.00 Occupation Student 40(6.6) 6(15.0) 34(85.0) 0.46 (0.22-0.97) 0.020* Signed labor 118(19.4) 22(18.6) 96(81.4) 0.57 (0.38-0.85) 0.002* Self-employed 132(21.7) 52(39.4) 80(60.6) 1.35 (1.04-1.73) 0.026* Housewife 187(30.8) 77(41.2) 110(58.8) 1.52 (1.20-1.91) 0.000* Unemployed/Retired/Pensioner 130(21.5) 34(26.2) 96(73.8) Yes 525(86.5) 178(33.9) 347(66.1) No 82(13.5) 13(15.9) 69(84.1) 1.00 With Cildren 2.14 (1.28-3.57) 0.001* 1.00 Years of education None 33(5.4) 8(24.2) 25(75.8) 1 to 3 years 58(9.6) 18(31.0) 40(69.0) 1.01 (0.68-1.51) 1.00 0.954 4 to 7 years 159(26.2) 66(41.5) 93(58.5) 1.49 (1.17-1.81) 0.001* 8 to 11 years 275(45.3) 87(31.6) 188(68.4) 1.01 (0.80-1.28) 0.934 ≥12 years 82(13.5) 12(14.6) 70(85.4) 0.43 (0.25-0.73) 0.000* One resident 37(6.1) 14(37.8) 23(62.2) 2 to 3 people 107(17.6) 30(28.0) 77(72.0) 0.87 (0.63-1.21) 0.400 4 or more 463(76.3) 147(31.7) 316(68.3) 1.04 (0.79-1.37) 0.787 0.010* Living in the household 1.00 Income Up to 1 MW 69(11.4) 31(44.9) 38(55.1) 1.51 (1.13-2.02) 1 to 3 MW 401(66.1) 132(32.9) 269(67.1) 1.14 (0.88-1.48) 0.299 4 to 6 MW 121(19.9) 28(23.1) 93(76.9) 0.69 (0.49-0.98) 0.026* 15(2.5) - 15(100.0) 0.00 (0.00-0.72) 0.003* Owned 424(69.9) 125(29.5) 299(70.5) 0.86 (0.67-1.10) 0.240 Rented 162(26.7) 57(35.2) 105(64.8) 1.17 (0.91-1.50) 0.233 21(3.5) 9(42.9) 12(57.1) ≥7 MW Housing Borrowed/donated MW - Minimum Wage; SRQ 20 - Self Report Questionnaire 20; PR - Prevalence Ratio; CI - Confidence Interval; Chi-square (c)2; *p<0.05; n=607 202 Acta Paul Enferm. 2014; 27(3):200-7. 1.00 Lucchese R, Sousa K, Bonfin SP, Vera I, Santana FR 100 90 80 70 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Yes No 1- Do you often have headaches?; 2- Is your appetite poor?; 3- Do you sleep badly?; 4- Are you easily frightened?; 5- Do your hands shake?; 6- Do you feel nervous, tense or worried?; 7- Is your digestion poor?; 8- Do you have trouble thinking clearly?; 9- Do you feel unhappy?; 10- Do you cry more than usual?; 11- Do you find it difficult to enjoy your daily activities?; 12- Do you find it difficult to make decisions?; 13- Is your daily work suffering?; 14- Are you unable to play a useful role in life?; 15- Have you lost interest in things?; 16- Do you feel that you are a worthless person?; 17- Has the thought of ending your life been on your mind?; 18- Do you feel tired all the time?; 19- Are you easily tired?; 20- Do you have uncomfortable feelings in your stomach? Figure 1. Affirmative and negative answers among the 191 individuals who had a score of ≥ 7 After univariate analysis, there was an association with the outcome in the following predictive variables: gender p=0.000 (PR:0.32 [CI 95%: 0.200.50]); single marital status p=0.018 (PR:0.64 [CI 95%: 0.44- 0.95]); occupation student p=0.020 (PR:0.46 [CI 95%: 0.22- 0.97]); signed labor p=0.002 (PR:0.57 [CI 95%: 0.38- 0.85]); occupation self-employed p=0.026 (PR:1.35 [CI 95%: 1.04- 1.73]); housewife p=0.000 (PR:1.52 [CI 95%: 1.20- 1.91]); with children p=0.001 (PR:2.14 [CI 95%: 1.28- 3.57]); 4 to 7 years of education p=0.001 (PR:1.49 [CI 95%: 1.17- 1.81]); ≥12 years of education p=0.000 (PR:0.43 [CI 95%: 0.250.73]); income up to 1 minimum wage p=0.010 (PR:1.51 [CI 95%: 1.13- 2.02]); income of 4 to 6 minimum wages p=0.026 (PR:0.69 [CI 95%: 0.490.98]); income of ≥7 minimum wages p=0.003 (PR:0.00 [CI 95%: 0.00- 0.72]). Regarding the questions explored by the SRQ-20, figure 1 describes the negative and affirmative answers among the 191 subjects who had a score of ≥7. Of the answers obtained with the tracking instrument of common mental disorder, the answer YES prevailed for: feeling nervous, tense or worried (65.7%), feeling unhappy (41.4%) and often having headaches (39.4%). On the other hand, the highest prevalence of NO answers was for: the thought of ending life (94.9%), suffering daily work (92.9%) and feeling worthless (88.9%). Discussion The limitations involving this study include its sectional methodological design, which does not allow inferring a causal connection, as it describes the phenomenon at a given place and time. Another limitation concerns the convenience sampling technique. Acta Paul Enferm. 2014; 27(3):200-7. 203 Prevalence of common mental disorders in primary health care However, the results of the study estimated the prevalence of common mental disorder and described relevant characteristics of people who obtained a score of ≥7 in the SRQ-20, such as symptoms related to depression, anxiety and somatotropics, which indicate the need for better organization of primary health care and family care in the development of mental health promotion. These aspects contribute to the development of nursing practices, as the instrument used was low-cost, easy to interpret and can be largely applied by the health staff, especially the nursing staff in the tracking of non-psychotic mental disorders, in order to revert the underreporting of this morbidity, as noted by some authors.(5,7) Regarding the results, this study showed that the prevalence of suspected cases of common mental disorder within the population studied was 31.47%, which confirms the results obtained by other studies carried out in other parts of Brazil using the SRQ-20 test.(5,7,11) In these studies, the prevalence of non-psychotic disorders varied 28.7% in a municipality of Santa Cruz do Sul, southern Brazil; 29.9% in Feira de Santana, northeastern region; 39.44% in Blumenau, southern region.(5,10,11) The highest percentage was found in the municipality of São João Del-Rei, southeastern region, with 43.70%.(7) When the sociodemographic particularities were considered, a lower prevalence was observed among men regarding non-psychotic morbidities when compared to women; and this was also observed in other studies.(2,5,7,10-13) Considering the strong relationship between men and work, it is understood that any mistake or failure may affect the social and personal context, resulting in emotional/psychological problems. Nevertheless, a closer link between women and common mental disorder can be established due to work and family responsibility, as they frequently give up self-care to dedicate themselves to others, resulting in dismay, anxiety, frustration, angst, illness, and most of all, the occurrence of mental disorders.(13,14) After a bibliographic review of the literature, the systematic knowledge regarding inequalities of 204 Acta Paul Enferm. 2014; 27(3):200-7. gender and common mental disorder revealed that high rates of disorders in women result from their depreciation within society, from weariness due to workload both at home and at work, and from violence they suffered from their partners. Moreover, women easily notice their illness, promptly report their symptoms and search for health services more frequently than men.(3) Regarding marital status, the association of common mental disorder with being single revealed an unprecedented event in this study when compared with previous ones, which presented an association of common mental disorder with divorced or separated and widowed individuals. (11,12) There is a contradiction regarding a significant statistical association of marital status with common mental disorder when we say that family coexistence is essential for the individual’s conception as a social element, as it is within the family environment that one outlines the constitution of the individual, the organization of the identity, the psychological development and personality.(12) Based on the derivatives related to occupation, the association in this study of common mental disorder with the predictive variables of being a “housewife” and “self-employed” corresponds to the categories with the largest predisposition to common mental disorder. In that sense, housewives perform household duties and are closely related to risk variables for depression and anxiety. This risk is explained by the fact that these women, by being isolated at home, are forced to give up on their professional satisfaction and consequently on their socialization.(15) On the other hand, most self-employed workers, who can be classified as informal workers since they do not have a signed labor, experience situations such as uncertainty regarding their working situation, income restraint, lack of social benefits and lack of protection from labor legislation; and all of these factors trigger anxiety and depression.(3) Therefore, when it comes to the “occupation” variable, the individuals who showed lower probability of having common mental disorder were students and individuals with a signed labor contract. Lucchese R, Sousa K, Bonfin SP, Vera I, Santana FR Another significant statistical association with common mental disorder in this study was the predictive variable “with children”. The disorders resulting from the duality of roles played, that comprehends both the upbringing of children and responsibilities regarding profession, were confirmed by the results of a previous research, which revealed that having children may be a risk factor for the occurrence of common mental disorder among female workers but not among housewives.(16) Regarding the years of education, there was a prevalence of the interest condition in the group with common mental disorder in relation to the non-exposed group, that is, which did not present common mental disorder in two periods of education. The interviewees who declared having studied for 4 to 7 years showed lower probability of having common mental disorder. This finding does not differ substantially from that described in another study with individuals in primary health care who had the same education level.(7) A greater number of years of education also represented a lower probability of having common mental disorder, so those who have higher education have fewer chances of developing non-severe disorders. Generally speaking, this inverse linear correlation between the chances of having a disorder and education level is also revealed by other researchers.(17) On the other hand, fewer years of education is a factor that is closely related to the occurrence of non-psychotic disorder. This fact implies in difficulties in entering the work market, low income, lack of appreciation and uncertain life conditions; and it may be considered to be the root of other social problems resulting in poor quality of life and consequent psychological problems in the future.(17) In the current social context, many children that come from low income families usually drop out of school as they need to work to contribute to the household income. The fact that these families have low income is mostly due to the fact that parents did not have a higher level of labor insertion. Consequently, this problem becomes cyclical and affects general health conditions and essentially mental health.(17) Regarding monthly incomes, individuals who had up to one minimum wage of income showed higher probability of developing common mental disorder. This finding also came up in another research in which subjects with incomes under or equal to one minimum wage were more likely to have non-psychotic disorders.(11) An inverse relationship regarding wealthier people (more than 4 MW) was also observed and confirmed by a previous study, in which lower family incomes of participants indicated more probability for mental disorders.(7) This relationship was also highlighted by the indication that people who lived with less than one minimum wage were four times more likely to have common mental disorder than people who lived with more than three minimum wages.(16) Therefore, low incomes are related to high rates of psychological problems arousing from a decrease of power, greater uncertainty, a painful compliance with social rules, stressful events in daily life that result in low self-esteem and, consequently, in greater chances of developing mental disorders.(3,7) Regarding the questionnaire, from the answers obtained with the help of SRQ-20 to indicate common mental disorder, it is important to highlight the prevalence of an anxious-depressed mood resulting from feelings of nervousness, tension or worries, along with somatic symptoms and frequent headaches. This set of symptoms also prevailed in another study.(15) Individuals who were more likely to develop a common mental disorder have different levels of anxious, depressive or somatoform disorders.(2) In view of this situation, it is recommended that the search for common mental disorder be systematized in primary health care, as well as specific mental health care actions at this level.(17) Consequently, within the population studied, a lower prevalence of thoughts such as giving an end to life or feeling worthless was observed. From this analysis, there is a certain profile of Acta Paul Enferm. 2014; 27(3):200-7. 205 Prevalence of common mental disorders in primary health care individuals that stands out: those who are more affected by an anxious-depressive mood and less by suicidal thoughts. A higher rate of “NO” answers was observed for symptoms of decrease of vital energy in the item “suffering daily work”. Despite the fact that the “housewife” and “self-employed” occupations presented an association with common mental disorder through the univariate analysis, occupation was not considered to be a relevant factor for the decrease of vital energy. In that sense, it is understood that the occupation appears in the health-illness process proportionally to the degree of expectations experienced by the worker. Factors such as overload, underload, lack of control over work, gap between control groups and subordinate staff, social withdrawal in the work environment, role conflicts, social disorder and absence of social support can cause physical and mental suffering.(18) Conclusion The prevalence of common mental disorder was higher among women, divorced individuals, Asian, aged between 18 and 59 years, housewives, individuals with children, having four to seven years of education, income up to one minimum age and living in a borrowed or donated house. Collaborations Lucchese R participated in the conception of the project, analysis and interpretation of data, writing of the article, critical review of the content and final approval of the version to be published. Santana FR participated in the conception of the project, critical review of the content and final approval of the version to be published. Vera I participated in the analysis and interpretation of data, critical review of the content and final approval of the version to be published. Sousa K and Bonfim SP were field researchers, and participated in the writing of the article, critical review of the content and final approval of the version to be published. 206 Acta Paul Enferm. 2014; 27(3):200-7. References 1. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health without mental health. Global Mental Health. Lancet. 2007;370:859-77. 2. Skapinakis P, Bellos S, Koupidis S, Grammatikopoulos L, Theodorakis PN, Mavreas V. Prevalence and sociodemographic associations of common mental disorders in a nationally representative sample of the general population of Greece. BMC Psychiatry. 2013;13:163. 3. Ludemir AB. [Class and gender inequalities and mental health in the cities]. Physis. 2008; 18(3):451-67. Portuguese. 4. Fone D, Greene G, Farewell D, White J, Kelly M, Dunstan F. [Common mental disorders, neighbourhood income inequality and income deprivation: small-area multilevel analysis]. Br J Psychiatry. 2013;202(4): 286–293. 5. Gonçalves DM, Stein A T, Kapczinski F. [Performance of the SelfReporting Questionnaire as a psychiatric screening questionnaire: a comparative study with Structured Clinical Interview for DSM-IV-TR]. Cad Saúde Pública. 2008; 24(2): 380-90. Portuguese 6. Fortes S, Lopes CS, Villano LA, Campos MR, Gonçalves DA, Mari JJ. [Common mental disorders in Petrópolis-RJ: a challenge to integrate mental health into primary care strategies]. Rev Bras Psiquiatr. 2011; 33(2):150-6. Portuguese. 7. Moreira JK, Bandeira M; Cardoso CS; Scalon JD. [Prevalence of common mental disorders in the population attended by the Family Health Program]. J Bras Psiquiatr. 2011;60(3):221-6. Portuguese. 8. Borim FS, Barros MB, Botega NJ. [Common mental disorders among elderly individuals: a population-based study in Campinas, São Paulo State, Brazil]. Cad Saúde Coletiva. 2013;29(7):1415-26. Portuguese. 9. Santos KO, Araújo TM, Oliveira NF. [Factor structure and internal consistency of the Self- Reporting questionnaire (SRQ-20) in an urban population]. Cad Saúde Pública. 2009;25(1):214-22. Portuguese. 10. Helena ET, Lasagno BG, Vieira R. [Prevalence of non-psychotic mental disorders and associated factors in people with hypertension and/or diabetes from Family Health Units in Blumenau, Santa Catarina, Brazil]. Rev Bras Med Fam Comunidade. 2010; 17(5): 42-7. Portuguese. 11. Rocha SV, Almeida MM, Araújo TM, Júnior JS. 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[Common mental disorders among workers in the urban area of Feira de Santana – Bahia-Brazil]. Rev Bras Saúde Ocup. 2011; 36 (123): 25-39. Portuguese. Lucchese R, Sousa K, Bonfin SP, Vera I, Santana FR 17.Fonseca ML, Guimarães MB, Vasconcelos EM. [Diffuse distress and common mental disorders: a bibliographic review]. Rev APS. 2008;11(3): 285-94. Portuguese. 18. Souza SF, Carvalho FM, Araújo TM, Porto LA. [Psychosocial factors of work and mental disorders in electricians] Rev Saúde Pública. 2010; 44(4):710-7. Portuguese. Acta Paul Enferm. 2014; 27(3):200-7. 207 Original Article Prevalence of depressive symptoms and associated factors among institutionalized elderly Prevalência de sintomatologia depressiva e fatores associados entre idosos institucionalizados Márcia Carréra Campos Leal1 João Luis Alves Apóstolo2 Aída Maria de Oliveira Cruz Mendes2 Ana Paula de Oliveira Marques1 Keywords Geriatric nursing, Nursing assessment; Aging; Aged; Depression; Prevalence Descritores Enfermagem geriátrica; Avaliação em enfermagem; Envelhecimento; Idoso; Depressão; Prevalência Submitted January 14, 2014 Accepted May 26, 2014 Abstract Objective: Determining the prevalence of depressive symptoms and associated factors in institutionalized elderly. Methods: Cross-sectional study that included 211 elderly from Brazil and 342 from Portugal, all residing in long-stay institutions. The survey instrument was the Geriatric Depression Scale. Results: The prevalence of depressive symptoms was found among 49.76% of the elderly in Brazil and in 61.40% of the Portuguese seniors. The Brazilian elderly with depressive symptomatology have the single marital status, low number of years of study and gender as main associated factors. Among the Portuguese elderly, the main associated factor was the age over 70 years. Conclusion: The prevalence of depressive symptoms was high and its early recognition may contribute to the quality of life of institutionalized elderly. Resumo Objetivo: Conhecer a prevalência da sintomatologia depressiva e fatores associados em idosos institucionalizados. Métodos: Estudo transversal que incluiu 211 idosos brasileiros e 342 idosos portugueses, residentes em instituições de longa permanência. O instrumento de pesquisa foi a Escala de Depressão Geriátrica. Resultados: A prevalência de sintomatologia depressiva encontrada foi 49,76% entre idosos brasileiros e 61,40% em portugueses. Idosos brasileiros com sintomatologia depressiva têm como principais fatores associados o estado civil solteiro, o baixo número de anos de estudo e o sexo. Entre idosos portugueses o principal fator associado foi a idade maior do que 70 anos. Conclusão: A prevalência da sintomatologia depressiva foi alta e o seu reconhecimento precoce pode contribuir para a qualidade de vida e idosos institucionalizados. Corresponding author Márcia Carréra Campos Leal Prof. Moraes Rego Avenue, 1235, Recife, PE, Brazil. Zip Code: 50670-901 [email protected] DOI http://dx.doi.org/10.1590/19820194201400036 208 Acta Paul Enferm. 2014; 27(3):208-14. Universidade Federal de Pernambuco, Recife, PE, Brazil. Escola Superior de Enfermagem, Universidade de Coimbra, Coimbra, Portugal. Conflicts of interest: no conflicts of interest to declare. 1 2 Leal MC, Apóstolo JL, Mendes AM, Marques AP Introduction Population aging is a global reality that is happening in different countries, including Brazil and Portugal, although each of these countries is at different stages of this transition. Thus, within a few years we will have more people aged over 60 years, with a larger number of people reaching older ages, exceeding the life expectancy predicted by experts.(1) The World Health Organization considers as elderly in developing countries any person older than 60 years, and in developed countries, people aged over 65 years.(2) According to the same source, there is a statistical forecast for 2025 of an elderly population of 1.2 billion people in the world. A curious fact is that the older population, those aged over 80 years, will be the fastest growing age group. According to the Brazilian Institute of Geography and Statistics (IBGE - Instituto Brasileiro de Geografia e Estatística),(3) the Brazilian population is 190,732,694 people, with about 10% aged over 60 years. Life expectancy for women is 77 years and for men is 69.4 years. According to the National Institute of Statistics, in Portugal(4) there are 10,561,614 inhabitants, among which 19% are elderly. The European country has a life expectancy of 81.8 years for women and of 75.8 years for men. The strategy for health promotion aimed at the aging population in Brazil is supported by the National Health Policy for the Elderly.(5) And in Portugal, through the National Programme for the Health of the Elderly.(6) Due to the increasing number of elderly and the difficulties faced by families in the task of caring (related to changes in family structure, such as the emergence of smaller families and an increasing individual mobility because of work obligations), arises the necessity for Institutions for the Aged, which are places of comprehensive care for older people who are unable to stay with their families or in their own homes. The aging process causes changes in the pattern of diseases and in the frequency of disabilities.(7) The physical, cognitive and sensory functions are weakened, leading to deterioration of functional abilities.(8) Therefore, a high prevalence of mental disorders is noticeable at the old age, among which predominates the depression.(9) According to the literature, depression is common in old age, but contrary to popular opinion, is not part of the natural aging process. In most cases, depression is underdiagnosed and undertreated. It is observed that among institutionalized elderly, depression often remains undiagnosed and untreated, especially in institutions without a team of professionals with knowledge and skills to identify patients at risk. Hence, the necessity to enable these professionals to recognize the most common ways in which the depressive syndromes are presented.(10) Thus, in relation to affective disorders, depression imposes itself as the most frequent in the elderly, currently becoming the leading cause of disability worldwide. According to Apóstolo et al.,(11) depression is responsible for 6.2% of the morbidity rate in the European region of the World Health Organization. Considering the increase of the elderly population worldwide, we understand the need for studies involving different countries, in order to track changes and possible differences in the dynamics of aging. Thus, enabling improvements in the life condition of the elderly. Based on the above, this study was carried out in two different scenarios, assessing the elderly in a Latin American developing country and in a developed European country, aiming at evaluating and comparing the depressive symptoms and socio-demographic factors among institutionalized elderly in Brazil and Portugal. The hypothesis was that the comparative analysis would enable knowing the greater or lesser proximity of the two countries regarding the prevalence of depressive symptoms and associated factors, inferring if these can serve as indicators of trends or not. I.e., under a specific parameter, the analysis should permit evaluating the current demographic and epidemiological transition stage of Brazil in relation to Portugal. This study aimed at knowing the prevalence of depressive symptoms and socio-demographic factors in institutionalized elderly. Acta Paul Enferm. 2014; 27(3):208-14. 209 Prevalence of depressive symptoms and associated factors among institutionalized elderly Methods This is a cross-sectional study carried out in two scenarios: the city of Recife, northeastern Brazil and the city of Coimbra, in Portugal. The sample consisted of 211 Brazilian seniors and 342 Portuguese seniors aged over 60 years and residents of long-stay institutions. The proportional stratified sampling technique was used to select the sample, allowing the choice of its components depending on the actual distribution of strata in the population. Data collection was obtained through interviews with socio-demographic features and the Geriatric Depression Scale of 15 items. The interviews with the Portuguese population were conducted by researchers at the Research Unit in Health Sciences: Nursing, of the Escola Superior de Enfermagem de Coimbra. For the Brazilian population, the interviews were conducted by researchers of the Research Group – Health of the Elderly of the Universidade Federal de Pernambuco. The presence of depressive symptoms was assessed using the Geriatric Depression Scale with 15 items, a short version of the original scale.(12-14) The Geriatric Depression Scale with 15 items is one of the most used tools for detecting depression in the elderly. Several studies have shown that this scale provides valid and reliable measures for the assessment of depressive disorders, thus justifying its choice. The cutoff used for suspected depression was > 5. The Statistical Package for the Social Sciences, version 16.0 was used for data management. After data collection, the information was entered into a database of the statistical program. First, the data were descriptively analyzed with dispersion measures for the numeric variable of age. Tables and graphs were generated for the subsequent bivariate analysis in each of the countries, considering the depressive symptoms as the dependent variable. After checking the associations, the profile analysis was done only of respondents with depressive symptoms. In order to define the most important features, a classification/decision tree was generated based on the origin of the respondents, i.e., Brazil or Portugal, 210 Acta Paul Enferm. 2014; 27(3):208-14. through computer simulations, using the aforementioned statistical tool. The development of study followed the national and international standards of ethics in research involving human beings. Results Using the chi-square test to assess the association between the dependent variables and depressive symptoms in each country separately, and considering a significance level of 5%, the table 1 shows that in Brazil the hypothesis of independence of depressive symptoms in relation to gender and age was rejected. When evaluating the results of the same statistical tests in Portugal, the hypothesis of independence of depressive symptoms with any of the variables was not rejected. As the p-value of the Pearson’s chi-squared test for the intersection between the depressive symptoms variable and the country of respondents was lower than 0.05 (5%), we can consider there is an association between them. For this reason, we performed an analysis to define the profile of the elderly with depressive symptoms in each country. It is noteworthy that the percentage distribution of each category of the analyzed variables is different when considering Brazil and Portugal separately. (Table 2) In order to assess the main characteristics of elderly patients with depressive symptomatology in Brazil and Portugal and recommend an appropriate classification, a decision/classification tree was proposed using the Statistical Package for the Social Sciences version 16.0. The growth algorithm chosen was the “EXHAUSTIVE CHAID,” which is a variation of the standard algorithm “CHAID” that is based on the existing associations in each of the growth steps, through the Pearson’s chi-squared test. At the first level, it is noted the separation by marital status: most seniors with depressive symptomatology in Brazil (54 cases) was observed in the category of singles, while in Portugal most respondents (183 cases) are widowed or maintain stable relationships. Leal MC, Apóstolo JL, Mendes AM, Marques AP Table 1. Factors associated with depressive symptoms Table 2. Positive depressive symptomatology Country Variables Brazil Frequency (%) Country Portugal p-value Frequency (%) p-value Brazil Portugal Frequency (%) Frequency (%) Female 85(81.0) 131(62.4) Male 20(19.0) 79(37.6) Variables Gender Female 147(69.67) 0.0 215(62.87) Male 64(30.33) 0.21 127(37.13) 0.82 Gender Age 60 |- 70 years 61(28.91) 70 |- 80 years 72(34.12) 80 |- 90 years 57(27.01) 90 and over 24(7.02) 0.18 0.96 Age 85(24.85) 176(51.46) 60 |- 70 years 29(27.6) 15(7.1) 21(9.95) 57(16.67) 70 |- 80 years 33(31.4) 54(25.7) 80 |- 90 years 28(26.7) 107(51.0) 18(8.53) 70(20.47) 90 |- 15(14.3) 34(16.2) Single 113(53.55) 44(12.87) Widowed 55(26.07) Separated/ Divorced 24(11.37) 67(19.59) 7(6.7) 41(19.5) 1(0.47) 0(0.00) Single 54(51.4) 27(12.9) Widowed 27(25.7) 98(46.7) Separated/ Divorced 17(16.2) 44(21.0) 01 |- 05 42(40.0) 141(67.1) 05 |- 09 9(8.6) 8(3.8) 09 |- 12 7(6.7) 7(3.3) 12 or more 3(2.9) 3(1.4) 44(41.9) 51(24.3) Marital status Married/ Living with partner Not informed 0.08 0.86 Marital status 161(47.08) Married/ Living with partner Years of education/study 01 |- 05 86(40.76) 219(64.04) 05 |- 09 28(13.27) 15(4.39) 09 |- 12 17(8.06) 11(3.22) 12 or more 8(3.79) 6(1.75) 72(34.12) 91(26.61) None/Unknown/Not informed 0.61 Depressive symptomatology With 105(49.76) 210(61.40) Without 106(50.24) 132(38.60) At the second level, when it comes to Brazil, most of the respondents with depressive symptoms is illiterate or has few years of study (32 cases), while in Portugal, in the second level of the tree, most of the elderly is older than 70 years (171 cases). It is only at the third level that the Portuguese elderly appear to be more sensitive to the few years of study (81 cases) and the Brazilians with respect to the female gender (13 cases). Brazilian elderly with depressive symptomatology have as main associated factors, the single marital status, the few years of study and gender. In contrast, the Portuguese elderly have as main factors associated with depressive symptoms not belonging to the single marital status and age older than 70 years. Education, which appears as the second most important characteristic among Brazilians, is the third strongest among the Portuguese elderly. Years of education/study None/Not informed In order to verify if the age of respondents with depressive symptoms was the same in the two countries, the t-test was applied to determine the equality of means. The Brazilian mean obtained was of 81.14 years and the Portuguese mean was of 82.22 years. The statistical test generated a p-value of 0.6855, i.e., considering a significance level of 5%, there is no statistical evidence that the mean ages among patients of Brazil and Portugal are different. Therefore, in the studied sample the most important factor for Brazilian respondents was the marital status, assuming that singles seem to be at higher risk of depression, while in Portugal, being single does not appear to be a risk factor as significant, if compared to Brazil. The average age of the respondents in both countries was statistically the same, but the majority of Portuguese respondents Acta Paul Enferm. 2014; 27(3):208-14. 211 Prevalence of depressive symptoms and associated factors among institutionalized elderly Figure 1. Classification/decision tree with depression was aged between 70 and 90 years, whereas, among Brazilians, the distribution was more uniform in the various categorizations of age (Figura 1). Discussion The limitations of this study results are related to the cross-sectional design that does not allow establishing relations of cause and effect. The importance of the results obtained for nursing professionals together with the health team is noteworthy. Acquiring knowledge about the aging process and the diseases that can affect the elder- 212 Acta Paul Enferm. 2014; 27(3):208-14. ly, including depression, makes these professionals more alert, in the sense of identifying the needs of the elderly, minimizing the existing difficulties and favoring a better quality of life. Regarding gender, the sample of institutionalized elderly, both in the cities of Recife and Coimbra, showed a higher percentage of women, of 69.67% and 62.87% respectively, which is the same data found in other studies, reinforcing the feminization of ageing.(15,16) Regarding the age factor, it was observed that in Recife the highest prevalence was found in the age group of 70-80 years (34.12%) and that, in Coimbra, it was between 80 and 90 years (51.46%), which corresponds to a higher life expectancy in de- Leal MC, Apóstolo JL, Mendes AM, Marques AP veloped countries. According to data from the Brazilian Institute of Geography and Statistics,(3) life expectancy for women is 77 years and for men, 69.4 years. In Portugal, the National Institute of Statistics (4) has a life expectancy of 81.8 years for women and of 75.8 years for men. These differences, however, do not hide the common trend for both countries of institutionalization occurring at older ages. In relation to marital status, the single and widowed participants of Brazilian institutions reached a percentage of 79.62%, while in Portugal the widowed and separated/divorced participants reached 66.65%. The result corroborates other studies and justifies the search for these institutions at that time of life when finding oneself alone. This search may also occur as a personal initiative, often due to external pressures, fear of urban violence, exclusion of the family, and especially for believing in the quality of care provided in Long-Stay Institutions for the Elderly.(15,17) Considering the level of education of the participants, we found that the two groups have low level of education: a high percentage, of approximately 74.88% of Brazilians and 90.65% of Portuguese, have up to 5 years of study. We can consider that the low level of education of institutionalized elderly is probably due to the difficulty of access to education experienced a few decades ago, especially for women.(16,18,19) We believe that the institutionalization of the elderly can be a potentiating condition of depression, because by living in this new environment, isolated from their social life and away from their families, they need to adapt to all these changes. According to Salgueiro,(20) the elderly leave their homes, no longer have their own time, lose their autonomy and become dependent on third parties, which could trigger depressive states. Thus, we find in national and international scientific literature a high prevalence of depression in institutionalized elderly. Regarding the Brazilian institutionalized elderly, the prevalence of depressive symptoms is equivalent to 49.76%, a result that approaches other studies such as the one by Soares et al.,(16) that obtained an extremely high prevalence of 73.7% in institutionalized elderly, as well as the study by Maciel and Guerra,(21) with a prevalence of depressive symptoms of 25.5% for noninstitutionalized elderly. The prevalence of depressive symptoms in the Portuguese studied population was 61.40%. These values corroborate several studies, including the one by Vaz and Gaspar,(15) with prevalence of 47%. The information suggests that living in institutions probably requires actions that plan the comprehensive attention to the elderly more effectively, making it necessary to train the technical team who is responsible for the care. We emphasize that in addition to technical skills, we can not fail to encourage these professionals to cultivate a more human look to the limitations of the elderly. They must be reminded that caring is an act of love. Analyzing these data, we can corroborate the national and international studies, in which the number of institutionalized elderly with depressive symptoms is high, ranging from 25% to 80%. For Brazilian institutionalized elderly, the single marital status is a risk factor in relation to depressive symptoms. This fact is rarely discussed because in most studies, what is observed are gender issues, education and economic factors, i.e., an increased risk among women of low income and low education.(14,21) The environment of long-stay institutions provides challenges to residents and may favor the development of depressive symptoms. Therefore, the awareness of the diagnosis of depression in the institutional context by the technicians responsible for the care is of fundamental importance. The recognition of depression in the elderly should contribute to the development of strategies, favoring the effectiveness of treatment and, consequently, improving the Quality of Life of the Elderly. Conclusion The prevalence of depressive symptoms was high and its early recognition may contribute to the quality of life of institutionalized elderly. Collaborations Leal MCC and Apóstolo JLA contributed to the project design, study execution, analysis and interpretation of data, drafting the article and final approval of the version to be published. Mendes AMOC and Marques APO contributed to the projActa Paul Enferm. 2014; 27(3):208-14. 213 Prevalence of depressive symptoms and associated factors among institutionalized elderly ect design, drafting the article and critical revision for important intellectual content. References 1. Kanso S. Processo de envelhecimento populacional - um panorama mundial [Internet]. 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Original Article Ethical conflicts experienced by nurses during the organ donation process Conflitos éticos vivenciados por enfermeiros no processo de doação de órgãos Mara Nogueira de Araújo1 Maria Cristina Komatsu Braga Massarollo1 Keywords Ethics, nursing; Transplantation; Direct tissue donation; Conflict (Psychology); Qualitative research Descritores Ética em Enfermagem; Transplante; Doção dirigida de tecidos; Conflito (Psicologia); Pesquisa qualitativa Submitted January 13, 2014 Accepted April 29, 2014 Corresponding author Mara Nogueira de Araújo Doutor Enéas de Carvalho Aguiar Avenue, 419, São Paulo, SP, Brazil. Zip Code: 05403-000 [email protected] DOI http://dx.doi.org/10.1590/19820194201400037 Abstract Objective: To determine ethical conflicts experienced by nursing during the organ donation process. Methods: This qualitative study used the content analysis approach developed by Bardin. We interviewed eleven nurses who had cared for potential donors of organs for transplantation. Four questions were used to guide the interview. Results: After analysis, five categories emerged: difficulty in accepting brain death; non-acceptance of the multidisciplinary team for withdrawing mechanical ventilation of the non-donor patient after brain death; difficulty of the multidisciplinary team during the organ donation process; and situations that can interfere with the organ donation process and decision making in ethical conflicts. Conclusion: Ethical conflicts experienced by nurses during the organ donation process were difficulty of health care professionals in accepting brain death as the death of the individual, non-acceptance of withdrawing mechanical ventilation in non-donor patients after brain death, lack of knowledge to perform the brain death protocol, lack of commitment, negligence in care for potential donors, scarcity of human and material resources, religion, and lack of communication. Resumo Objetivo: Conhecer os conflitos éticos vivenciados pelos enfermeiros no processo de doação de órgãos. Métodos: Pesquisa qualitativa utilizando a análise de conteúdo de Bardin. Foram entrevistados onze enfermeiros, com experiência na assistência a potenciais doadores de órgãos para transplante. Foram utilizadas quatro questões norteadoras. Resultados: Emergiram cinco categorias: dificuldade em aceitar a morte encefálica; não aceitação da equipe multiprofissional de desconectar o ventilador mecânico do paciente em morte encefálica não doador de órgãos; dificuldades da equipe multiprofissional durante o processo de doação de órgãos; situações que podem interferir no processo de doação de órgãos e Tomada de decisão frente a conflitos éticos. Conclusão: Os conflitos éticos vivenciados pelos enfermeiros no processo de doação de órgãos foram: a dificuldade do profissional em aceitar a morte encefálica como morte do individuo, a não aceitação em desconectar o ventilador mecânico do paciente em morte encefálica e não doador de órgãos, o desconhecimento para a realização do protocolo de morte encefálica, a falta de comprometimento, o descaso no cuidado com o potencial doador a escassez de recursos humanos e materiais a crença religiosa e a falha na comunicação. Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, Brazil. Conflicts of interest: none reported. 1 Acta Paul Enferm. 2014; 27(3):215-20. 215 Ethical conflicts experienced by nurses during the organ donation process Introduction Organ transplantation is the last therapeutic alternative for patients with certain severe, acute or chronic disease when there are no other forms of treatment. Transplantation can reverse the clinical picture and aiming to improve the patient’s quality of life. The process of organ donation involves several agents and actions on the part of nursing professionals for the care of potential donors. The goal is to maintain hemodynamics and the viability of the organ for transplantation. Nurses are also responsible for coordinating the relationship with the donor’s families, who are experiencing the pain of losing a family member yet must also decide whether to donate their loved one’s organs. The actions of health professionals are guided by codes of professional ethics; however, the decision making can be based on the needs experienced in their day-to-day work.(1,2) Given the many advances in biomedical science that occurred in the second half of the 20th century, professional ethical codes are not enough. Organ and tissues transplantation brought extensive discussions about the ethics of decision-making with regard to encouraging organ donation and the process for donating and transplanting organs. (3) To solve conflicts, ethical analysis of all the related facts is necessary. Knowledge of the theoretical ethics that guide and systematize decision-making is also important. Considering this, knowledge of nurses’ ethical conflicts during the organ and tissues donation process can contribute to reflections and discussions concerning this topic and help the nursing team to understand and advise families as they make their decision. The objective of this study was to determine nurses’ ethical conflicts on the process for organ and tissue donation for transplantation and, in the face of these conflicts, to understand how decisions are made and what is take into consideration. Methods This qualitative study was carried out in a large hospital in São Paulo, Brazil, to determine the 216 Acta Paul Enferm. 2014; 27(3):215-20. experience of nurses facing ethical conflicts during the organ and tissue donation process. We included 11 nurses who delivered care for potential donors, for at least one year, at adult and pediatric critical care units, inpatient units, emergency departments, and surgical centers and nurses on the in-hospital committee for organ and tissues donation for transplantation. The following questions were used to guide the interviews: “During your professional experience, did any situations pose a conflict of ethics for you?” “Can you report some ethical conflicts that you experienced or observed while providing care of potential organ donors?” “How do you make a decision in a situation of ethical conflict?” “What do you consider when you are making a decision?” Discourses were analyzed using the content analysis approach proposed by Bardin. Development of this study followed national and international ethical aspects in research on human subjects. Results Eleven professionals who experienced ethical conflicts during the organ and tissue donation process participated in this study. Of these, nine were women and two were men; the age range was 26 to 39 years. The mean time since graduation from college was eight years. The participants had worked at the institution for four to 19 years. Most interviewees worked in adult and pediatric critical care units. The following categories were identified during analysis of the interview responses: Difficulty accepting brain death Not only physicians and nurses have difficulty accepting brain death; the family members of the potential donors do as well. The study participants expressed ambiguous feelings when confronted with the care of potential donor: While they recognized that the death of one patient can enable the other to continue living, they also were aware that the potential donor’s heart was still beating despite brain death and that the person should receive care in the same manner as if he or she were alive. Araújo MN, Massarollo MC The respondents also resisted starting the brain death protocol because of the difficulty in dealing with death and the acceptance the brain death; this behavior is a barrier to proving the diagnosis of brain death. The same was observed during the interview with family members who showed difficulty accepting brain death. Non-acceptance of multidisciplinary team of withdrawing mechanical ventilation to non-donor patient after brain death This category represents a major source of conflict experienced by nurses when physicians, and nurses themselves, are reluctant not withdraw mechanical ventilation for a brain-dead patient who is not an organ donor. Although nursing professionals are aware of the existence of legislation and institutional protocols to support the removal of mechanical ventilation, they emphasize the non-acceptance of withdrawing this measure. The difficulty concerns not only disconnecting the device but also explaining the situation to the family. For the nurse, removing mechanical ventilation from someone whose heart is beating, even after the diagnosis of brain death, generates the impression that he/she has given up and is “killing” the patient. Nurses also experience this feeling in situations when physicians are undecided about removing the device, and for them it appears that physicians are deciding whether they will let the patient die or not, although the patient is already dead. When nurses recognize that the institutional guidelines for removing mechanical ventilation in non-donor patients after brain death must be followed, they often find a barrier in the form of non-acceptance by physicians. This situation creates a stalemate between the nurse and physician. It also generates discomfort with regard to keeping a patient who has already died on artificial support, and postpones addressing the wishes of the family to receive their loved one’s body for a funeral. In addition, nurses report problems with families who do not agree to remove the support from the patient because they believe that a miracle will occur and the person will awaken. Difficulties of multidisciplinary team during the organ donation process Difficulties reported by the multidisciplinary team involve nurses’ conflicts during the organ donation process. These are related to the medical team’s lack of knowledge regarding how to carry out the brain death protocol and the lack of commitment on behalf of the health care professionals. This leads to negligence and inadequate assistance in caring for the brain-dead patient. Nurses reported that the medical team has doubts about how and when to determine brain death. This situation generates conflict for family members because they are informed before the diagnosis and for the nursing team, who, at the conclusion of the brain death protocol, have several questions that create uncertainty and doubt. This situation is even worse when there are divergent opinions among the medical team about the appropriate way to conduct the protocol. Situations that can interfere in the organ donation process The nurses identified the following situations as presenting ethical conflicts and as interfering in the organ donation process: religion, lack of communication, difficulties in interpersonal relationships, and scarcity of human and material resources. Nurses reported that such situations cause indifference, lack of commitment, and dissatisfaction, which affect the effective deployment of the process. Decision-making when facing ethical conflicts When nurses face ethical conflicts, they often make decisions based on discussion. They reported that communication and team work are important aspects in this process, but it was not clear from what basis the professional assumes a position regarding the conflict. Concerns about legislation and the principle of beneficence were identified when actions performed for the purpose of benefiting another person were mentioned. In the case of organ donation and transplantation, there is greater benefit with an intervention that saves lives. Acta Paul Enferm. 2014; 27(3):215-20. 217 Ethical conflicts experienced by nurses during the organ donation process Discussion Ethical conflicts experienced by nurses were structured into five categories. Their experience confirmed what has been described in other studies with nurses during the organ donation process. The analysis of results enables us to reflect on the perceptions of nurses who confront ethical conflicts in practice during the organ donation process. It also can be used to support professionals who seek to improve their actions in resolving ethical conflicts over organ and tissue donation for transplantation. Although the concept of death is related not only to cardiorespiratory arrest but also to the absence of cerebral and encephalic trunk activity (i.e., brain death equals death), several uncertainties exist among health professionals because of the belief that life exists while the heart is beating. For both the health care team and families, the maintenance of potential donors with a beating heart in the critical care unit generates the feeling that the patients are still alive. Currently, medical and nursing practice in the context of continual advances and increased technological resources results in a battle between knowledge and cultural pressures. Often, these situations imply changes in values about life, generating insecurity among professionals and repercussions for the patient. This reality indicates that society is still changing its perceptions about life and is still trying to understand the definition of death. Changes to culture and human values require time for the creation of new conceptions and experiences. Previous studies agree with these assumptions, having found that most of the studied populations did not accept brain death as death.(4-10) In Brazil, the diagnosis of brain death in patients with clinical signs of brain death is confirmed by two clinical exams and one complementary test, which are part of care delivery for patient and their families. A major conflict reported by the nurses in our study concerns withdrawing therapeutic support for non-donor patients with a diagnosis of brain death. The justification of withdrawal would be to avoid additional costs and avoid 218 Acta Paul Enferm. 2014; 27(3):215-20. prolonging the suffering of families. Despite knowledge of the existence of legislation and institutional protocols that support the disconnection of the ventilator, professionals emphasize non-acceptance for several reasons, such as the respect for personal, cultural, and social values; concern about creating conflicts with families who would not accept organ donation; concern regarding legal problems; lack of societal preparation to understand the procedure; and family members’ belief that the patient’s clinical course could reverse. Other studies agree with this affirmation and show that health care professionals have difficulty accepting the diagnosis of brain death as death and, consequently, do not accept withdrawal of life support after this diagnosis.(11,12) Removing life support might cause discomfort because the individual appears to be alive through artificial maintenance.(13) However, criteria for brain death seem to be accepted; there is little resistance to removal of the organs for transplant but rather to the withdrawing of devices. This contradiction leads to beliefs that brain death is usually considered only for transplantation, when, in fact, it means death, independent of whether or not the organs will be used. The beating heart affects the performance of the procedure, and this difficulty increases when there are conflicts between medical team and family members, or when personal values and religion are involved.(13,14) Difficulties reported by multidisciplinary teams during the organ donation process, such as lack of knowledge, negligence, and lack of commitment and professionalism, confirmed the results of earlier studies.(15-17) In general, research reveals that lack of knowledge about the organ donation process has a negative impact on attitudes toward organ donation, even among health professionals, which can lead to not identifying potential donors and not performing the brain death protocol, identified in practice by actions of professionals involved.(4-6,8) Nurses perceived religion, lack of communication, and scarcity of human and material resources as situations that could interfere in the process of organs donation. Religion is an important factor in decision-making in many areas. A study on religion and organ Araújo MN, Massarollo MC and tissue donation highlighted that any religion is absolutely opposed to organ donation; however, the degree of understanding about religions concerning the moment of death is diverse.(18) Some religions perform rituals with the body after death, which constitutes a negative factor for organ donation authorization.(18) In practice, some families have refused to donate and justify their decisions on the basis of their religion; the impression is that families invoke religion in an attempt to ameliorate the difficulty of making the decision.(14) Other conflicts experienced by nurses, such as the difficulty with interpersonal relationships and scarcity of human resources, can trigger disappointment, disrespect, lack of teamwork, and lack of communication, all of which result in negligence and poor care for the patient. The nurses in this study believe that these conflicts pose difficulties during development of their activities. To resolve conflicts, an ethical analysis of related facts is necessary, as is knowledge of the types of ethical theories to direct and systematize decision making.(19) However, in nurses’ decision making we did not identify ethical streams to support their positions. Nonetheless we did find support for the notion of beneficence and concern with legislation regarding brain death, and observed that the nurses emphasize use of discussion in these situations. Conclusion Ethical conflicts experienced by nurses during the organ donation process were health care professionals’ difficulty accepting brain death as the death of the individual, non-acceptance of withdrawing mechanical ventilation of the non-donor patient after brain death, lack of knowledge to perform the brain death protocol, lack of commitment, negligent care for the potential donor, scarcity of human and material resources, religion, and lack of communication. Collaborations Araújo MN and Massarollo MCKB contributed to the conception of the project, critical review to improve the manuscript intellectual content, drafting of the manuscript and approval of this final version for publication. References 1. Coelho LC, Rodrigues RA, Marcon SS, Lunardi VL. Conflitos éticos na revelação de informações - Parte II. Cienc Cuid Saúde. 2008; 7(1):7382. 2. Fernandes JD, Rosa DD, Vieira TT, Sadigursky D. Dimensão ética do fazer cotidiano no processo de formação do enfermeiro. Rev Esc Enferm USP. 2008;42(2):396-403. 3. Lima AA, Silva MJ, Pereira LL. Sofrimento e contradição:o significado da morte e do morrer para enfermeiros que trabalham no processo de doação de órgãos para transplante. Enferm Global. 2009;(15):1-16. 4. Teixeira RK, Gonçalves TB, Silva JA. A intenção de doar órgãos é influenciada pelo conhecimento populacional sobre morte encefálica? Rev Bras Ter Intensiva. 2012;24(3):258-62. 5. Cohen J, Ami SB, Ashkenazi T, Singer P. Attitude of health care professionals to brain death: influence on the organ donation process. Clin Transplant. 2008;22(2):211-5. 6. Escobar EM. Importancia de los cuidados intensivos en la donación y el trasplante de órganos. Rev Bras Ter Intensiva. 2012; 24(4):316-7. 7. Flóden A, Berg M, Forsberg A. ICY nurses’ perceptions of responsibilities and organization in relation to organ donation – A phenomenographic study. Intensive Crit Care Nurs. 2011;27(6):305-316. 8. Everidge CS, Donation After Cardiac Death – Ethical dilemmas and implications for advanced pratice nurses. Dimens Crit Care Nurs. 2012; 31(4):228-34. 9. Mathur M, Taylor S, Tiras K, Wilson M, Abd-Allah S. Pediatric critical care nurses’ perceptions, knowledge, and attitudes regarding organ donation after cardiac death. Pediatr Crit Care Med. 2008;9(3):261-9. 10.Moraes, EL, Carneiro AR, Araújo MN, Santos FS, Massarollo MC. Desconexão do ventilador mecânico de não doadores de órgãos: percepção de médicos intensivistas. Bioethikós (Centro Universitário São Camilo). 2011;5(4):419-26. 11. Shein AE, Carvalho PR, Rocha TS, Guedes RR, Moschetti L, Salvia JC, et al. Avaliação do conhecimento de intensivistas sobre morte encefálica. Rev Bras Ter Intensiva. 2008;20(2):144-148. 12. Bitencourt AG, Neves FB, Durães L, Nascimento DT, Neves NM, Torreão LA, et al. Avaliação do conhecimento de estudantes de medicina sobre morte encefálica. Rev Bras Ter Intensiva. 2007;19(2):144-50. 13. Lago PM, Piva J, Garcia PC, Troster E, Bousso A, Sarno MO, et al. Morte encefálica: condutas médicas adotadas em sete unidades de tratamento intensivo pediátrico brasileiras. J Pediatria. 2007;83(2):133-40. 14.Moraes EL, Massarollo MC. Recusa de doação de órgãos para transplante relatados por familiares de potenciais doadores. Acta Paul Enferm. 2009; 22(2):131-5. 15.Lemes MM, Bastos MA. Os cuidados de manutenção dos potenciais doadores de órgãos: estudo etnográfico sobre a vivência da equipe de enfermagem. Rev Latinoam Enferm. 2007;15(5):986-91. 16. Monteiro MA, Barbosa RC, Barroso MG, Vieira NF, Pinheiro AK. Dilemas éticos vivenciados por enfermeiros apresentados em publicações de enfermagem Rev Latinoam Enferm. 2008;16(6):1054-9. Acta Paul Enferm. 2014; 27(3):215-20. 219 Ethical conflicts experienced by nurses during the organ donation process 17. Guido LA, Linch GF, Andolhe R, Conegatto CC, Tonini CC. Estressores na assistência de enfermagem ao potencial doador de órgãos Rev Latinoam Enferm. 2009;17(6):1023-9. 18. Ambrosina M, Regina F. Crença religiosa e doação de órgãos e tecidos: 220 Acta Paul Enferm. 2014; 27(3):215-20. revisão integrativa da literatura. Rev Enferm UFSM. 2011;1(3):44-57. 19. Mascarenhas NB, Rosa DO. Bioética e formação do enfermeiro: uma interface necessária. Texto & Contexto Enferm. 2010;19(2):36671. Original Article Translation, adaptation and validation of a self-care scale for type 2 diabetes patients using insulin Tradução, adaptação e validação de uma escala para o autocuidado de portadores de diabetes mellitus tipo 2 em uso de insulina Thaís Santos Guerra Stacciarini1 Ana Emilia Pace2 Keywords Translating; Self care; Diabetes mellitus, type 2; Insulin; Validation studies Descritores Tradução; Autocuidado; Diabetes mellitus tipo 2; Insulina; Estudos de validação Submitted January 15, 2014 Accepted April 29, 2014 Corresponding author Thaís Santos Guerra Stacciarini Getúlio Guarita street, 130, Uberaba, MG, Brazil. Zip Code: 38025-180 [email protected] DOI http://dx.doi.org/10.1590/19820194201400038 Abstract Objective: Translate, adapt and validate the Appraisal of Self-care Agency Scale-Revised (ASAS-R) for Brazil. Methods: A descriptive method for adapting measurement instruments was used with 150 diabetes mellitus patients. The instrument underwent translation, synthesis of independent translations, evaluation by a committee of judges, back-translation and submittal of back-translation to original authors, semantic validation, submittal of the adapted version to original authors, and pretesting. Results: The ASAS-R maintained semantic, cultural and conceptual equivalence. Cronbach’s alpha was 0.74; the intraclass correlation coefficient for test-retest reliability was 0.81; and interobserver agreement was 0.84. Conclusion: The Brazilian-Portuguese version maintained conceptual, semantic and cultural validity, as compared to the original version. In the discriminant validity, there was correlation between capacity for selfcare, depression and perceived health, but not social support. There were significant differences between groups regarding age, education levels and insulin self-application. Resumo Objetivo: Traduzir, adaptar e validar a escala Appraisal of Self Care Agency Scale-Revised (ASAS-R) para o Brasil. Métodos: Utilizou-se o método descritivo de adaptação de instrumentos de medidas, em 150 portadores de diabetes mellitus. As etapas foram: tradução, síntese das traduções independentes, avaliação pelo Comitê de Juízes, retrotradução, submissão das versões retrotraduzidas aos autores da versão original, validação semântica, submissão da versão adaptada aos autores da versão original e pré-teste. Resultados: ASAS-R manteve as equivalências semântica, cultural e conceitual. O alfa de Cronbach foi de 0,74, e o coeficiente de correlação intraclasse, no teste e reteste, foi de 0,81, e na análise interobservadores, de 0,84. Conclusão: A versão manteve as equivalências conceitual, semântica e cultural. Confirmou-se a correlação entre os construtos capacidade de autocuidado, depressão e percepção do estado de saúde, exceto apoio social. Na validade discriminante, observaram-se diferenças significantes entre grupos, quanto à idade, escolaridade e autoaplicação de insulina. Hospital de Clínicas, Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brazil. Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil. Conflicts of interest: there are no conflicts of interest to report. 1 2 Acta Paul Enferm. 2014; 27(3):221-9. 221 Translation, adaptation and validation of a self-care scale for type 2 diabetes patients using insulin Introduction The recognition of chronic illnesses, in this case, of diabetes mellitus (DM), as serious public health problems(1) demands that different levels of the public health care system revise existing practices and implement actions for promoting self-care. According to Orem’s Self-Care Theory, selfcare is defined as actions initiated and carried out by individuals in order to maintain their life, health and well-being; individuals are an active part of the decision-making process, identifying their needs, and the actions to be undertaken for their care. In this context, it is essential for patients to take responsibility for home treatment, which is fundamental to controlling glucose levels and preventing acute and chronic complications. Such treatment involves behavioral changes in daily activities,(2) especially among patients of advanced age and who take insulin.(3) Some requisites for reaching treatment goals that have been much discussed are knowledge about DM and development of psychomotor skills.(2) These requisites promote and facilitate self-care activity management. However, patients must also display the ability to commit to/engage in self-care activities.(4-6) Self-care agency or power is a complex ability which is acquired and developed throughout one’s daily life. It enables a person to discern factors which must be controlled and treated, decide what can and must be done, recognize needs, assess personal and environmental resources, and determine, commit to and carry out self-care actions. Thus, an individual’s capacity to engage in self-care has been widely studied to demonstrate what individual actions can lead to health promotion, well-being and the maintenance and/or prevention of illnesses and their complications. (4-6) Such capacity can be studied regarding its development or operativity. Since capacity for self-care is a subjective construct which cannot be observed directly, but only through its attributes or indicators, it was necessary to find a measuring scale in the literature that could 222 Acta Paul Enferm. 2014; 27(3):221-9. evaluate a person’s capacity to engage in self-care activities according to new health care guidelines. Among the international scales found (The Exercise of Self-care Agency, The Denyes Selfcare Agency Instrument, The Perception of SelfCare Agency Questionnaire, The Self-as-Carer Inventory and The Mental Health-Related SelfCare Agency Scale),(4) the Appraisal of Self-care Agency Scale by Evers was chosen due to its popularity for use among the DM population, although it is not specific to this illness, and for being strongly correlated to other scales that measure self-efficacy, depression, social support, health status, health-promoting lifestyle and self-care management for DM patients, especially among those taking insulin.(4-6) This scale has been validated in the following countries: Sweden, Denmark, China, Norway, the Netherlands, the United States, Mexico and Colombia.(4) This scale was created based on concepts presented in Orem’s Theory of Self-Care Deficit, as analyzed by the Nursing Development Conference Group (NDCG). The items on the scale were constructed from the concept of capacity for self-care, based on enabling traits (10 power components), which are specific personal capacities for carrying out self-care activities. It is also based on operational traits, or the patient’s capacity for organizing personal and environmental resources significant for their self-care.(4,6) The scale does not mention the dimensions and does not aim at verifying whether capacity for selfcare is developed, but rather whether it is in operation. The instrument provides a global and nonspecific measurement, and can be applied to groups of different ages and health conditions. Its objective is to evaluate capacity for self‑care and measure the individual’s power to execute productive actions towards self-care. The revised version was chosen because it presented a better adjustment index, greater reliability and better validation results when compared to the original version. The changes presented in the new version were the exclusion of nine items and the description of three factors not reported in the original version. Stacciarini TS, Pace AE The ASAS-R is answered on a 5-point Likert scale and comprises 15 items with five possible answer choices each, only one being correct. A scoring is: totally disagree = 1; disagree = 2; neither disagree or agree = 3; agree = 4; totally agree = 5. Of the 15 questions, four refer to negative aspects, and their scores must be inverted for data analysis. The possible scores run from 15 to 75; the closer to 75, the higher the operational self-care capacity exhibited by the individual.(6) We believe that the use of the ASAS-R in Brazil will contribute towards nursing clinical practice and research on health care, especially regarding DM patients. The objective of the present study was to translate, culturally adapt and validate the Appraisal of Self-care Agency Scale-Revised (ASAS-R) to the Portuguese language and Brazilian culture. Methods A quantitative methodological study which deals with the process of translating, adapting and validating the ASAS-R scale to the Portuguese language with a group of Brazilians with diabetes mellitus type 2, all taking insulin. The authorized scale responsible for the translation and validation for Portuguese language The study was conducted in three public health units in a municipality of the state of Minas Gerais, an important economic center and regional reference in the field of health and education, in the period between November and September 2010. The translation and adaptation process for the ASAS-R followed methodological references(7-9) with the following modifications: we submitted a synthesis of the two translations to a committee of judges before the back-translation phase and included a semantic validation phase, in order to detect problems with item comprehension which might not have been noticed after back-translation and also to assess scale acceptance and comprehension by the target audience. Thus, the study went through the following phases: translation, synthesis of independent translations, evaluation by a committee of judges, back-translation, submitting back-translation to authors of the original version, semantic validation, submitting adapted version to the original authors and pretesting.(7-9) In the first phase, two bilingual specialists and native English speakers, residing in Brazil, translated the scale; the first translator was informed of the study’s objectives and had experience in the health field, unlike the second translator. A synthesized version was created based on the two translations, and together with the original scale, was submitted to the committee of judges for an evaluation regarding its semantic, idiomatic, conceptual and cultural equivalence, in order to guarantee comprehensibility, as well as face and content validity. The committee consisted of seven professionals with command of the English language that work in the fields of diabetes mellitus, selfcare, methodology for adapting measurement instruments and translation. The minimum level of agreement adopted was 80% in order for a modification to be accepted. Once the consensual version was ready, two American translators residing in Brazil who have command of the Portuguese language and Brazilian culture carried out a back-translation into English. However, they were not informed about the objective of the study, had no experience in the health care field, and worked independently. The back-translations were presented to the authors of the revised original version. After the authors’ agreement, the consensual version was submitted to a semantic validity analysis. During the semantic validation phase, it was submitted to 18 patients with diabetes mellitus, selected based on convenience. Participants were homogeneously distributed regarding gender and education level. There were six participants for every five items of the ASAS-R. All participants answered all the items of the first consensual version. However, every sixth participant also answered an instrument evaluating text comprehensibility and pertinence, as well as registering suggestions for every other fifth item on Acta Paul Enferm. 2014; 27(3):221-9. 223 Translation, adaptation and validation of a self-care scale for type 2 diabetes patients using insulin the scale. The scale was elaborated and the sample group selected based on methods used by researchers of the DISABKIDS Group.(10) The pretesting phase was conducted with the participation of 50 type 2 diabetes mellitus patients taking insulin, being attended to by the Family Health Strategy (ESF) unit. The main goals of this phase were to identify the need for new linguistic and conceptual adjustments to the scale, estimate the duration of the interview in minutes and conduct a preliminary analysis of the internal consistency and distribution of the answers. For analyzing the psychometric properties of the translated and adapted ASAS-R, 150 type 2 diabetes mellitus patients participated, all taking insulin and attended to by the three Family Health Strategy units, including those from the pretesting phase who fulfilled the following inclusion criteria: both genders; 18 years of age or older; over one year of having a type 2 diabetes mellitus diagnosis and of being registered in the ESF; using insulin; and a demonstrated capacity to answer the questions on the instrument. During this phase, the answers to the ASAS-R were analyzed for frequency distribution, reliability (internal consistency and product-moment correlation), replicability (test-retest and interobservers) and validity (convergent and discriminant construct validity). The internal consistency analysis of the items was obtained by means of Cronbach’s alpha (α), with acceptable values between 0.5 and 0.9, since it is a scale with few items. For analyzing replicability, the retest was applied to a sample of 30 people, obtained by the statistics program Statistical Package for the Social Sciences version 16.0, with an interval of time between interviews of 15 to 20 days. The first and second interviews were carried out by the same interviewer and in the same location. With regard to data collection for the interobserver agreement analysis, it was conducted on the same day, by different interviewers. The second interviewer was a nurse who received training about the studied construct, the instrument being validated and the interview method. The convenience sample comprised 30, and the intraclass correlation 224 Acta Paul Enferm. 2014; 27(3):221-9. coefficient statistical test was used for test and retest and interobserver agreement. For the analysis of convergent construct validity, we used the Depressive Cognition Scale (DCS) by Souza et al(11) (negative correlation), the Social Support Survey (MOS) by Griep et al(12) (positive correlation) and the instrument of Perceived Health Status questionnaire (SF-36) by Ciconelli et al(13) (positive correlation). The statistical test used was Pearson’s correlation coefficient. Regarding discriminant construct validity analysis, the results of comparisons between known groups were analyzed by means of Student’s t-test. This was done to test the hypothesis that the greater the education level and insulin self-application ability, the greater the score on the capacity for self-care evaluation scale; and the higher the age, the lower the score obtained the scale. Scales were applied to participants by the researcher of the present study, individually and through an interview. The study was developed according to national and international ethical norms for research with human beings. Results The two translated versions of the original ASAS-R displayed some differences in language. The version created by the translator who was informed about the study’s objectives and had knowledge in the field of health was directed towards the target audience’s culture and knowledge, while the version created by the translator who was not informed regarding the study’s objectives and had no experience in the health field was a more literary translation. The synthesized version submitted for evaluation by the committee of judges was subject to some modifications regarding word choice, subject-verb agreement and the conceptual definition of the term “self-care agency.” The term suggested instead was “capacity for self-care,” which is better known in Brazil and other Latin-American countries. This phase was concerned with preserving the meaning of the statements in order to ensure they remained Stacciarini TS, Pace AE as close as possible to the original version, while also guaranteeing the measurement’s replicability. In the semantic validation phase, participants pointed out their difficulties in understanding the completion instructions, one of the answer choices and six items on the scale. For a better level of understanding, researchers evaluated the doubts and suggestions, and carried out some adjustments whenever the level of agreement was less than 80%, while always endeavoring to maintain the meaning of the original items. We took measures, such as including an explanatory example in the completion instructions, to minimize random variation and increase measurement precision, substituting the answer choice “neither agree or disagree” for “undecided,” finding substitutes for words not frequently used in daily life, such as: circumstances, adjustments, energy and effectiveness, and making some terms more colloquial, as displayed in chart 1. After the suggested modifications were made, the second consensual version was submitted to the pretesting phase. In this step, a new modification was suggested; the interview time for completing the items was 5 minutes, the preliminary value of the items’ internal consistency was satisfactory (Cronbach’s alpha equal to 0.75) and ceiling and floor effects were observed for items ASAS-R 4, 7, 8, 11, 12 and 14 (more than 15% of the answers concentrated in the instrument’s lowest or highest possible scores). Thus, this second consensual version culminated in the adapted ASAS-R version. Analysis of the ASAS-R’s psychometric properties was carried out with the participation of 150 people, with sociodemographic and clinical characteristics as displayed below in table 1. In the same manner as in the pretesting phase, ASAS-R item distribution displayed ceiling or floor effects on items ASA-R 4, 7, 11, 12 and 14, except on item 8. As shown in table 2, we observed correlations with magnitudes varying from moderate to strong (r=0.31 to r=0.69) between 13 items on the ASAS-R, with exception of items ASAS-R 2, 9 and 13, which presented weak correlations (r=-0.18 to r=0.22). Item ASAS-R 13 was negatively correlated to the entire scale, however, its exclusion was not justifiable, for the alpha was not significantly altered. Chart 1. Items which underwent modification in the semantic validation phase Item ASAS-R VPC1 * BEFORE semantic analysis ASAS-R VPF** AFTER semantic analysis Instructions Instructions: Mark the best answer for each of the statements Instructions: Mark the best answer for each of the statements below, according to the scale. Example: Do you agree with item 1? If so, you will say/mark X in below, according to the scale the space for “agree or totally agree.” The difference between “agree and totally agree” is that “totally agree” gives an idea of always and “agree” gives an idea of most of the time. Example: I usually sleep enough to feel rested. Answer: If you are a person who always sleeps enough to feel rested, you will say/ mark “totally agree” for the phrase. However, if you sleep enough to feel rested most of the time, you will answer “agree.” This example is also relevant for the choices “totally disagree” and “disagree.” Answer choices Neither disagree nor agree ASAS- R 1 As the circumstances of my life change, I make the necessary As my life changes, I make the necessary changes to stay healthy. adjustments to stay healthy. ASAS- R 2 If my physical mobility is decreased, I make the necessary If my ability to move is decreased, I try to find ways to solve this difficulty. adjustments. ASAS- R 4 I frequently feel lack of energy to take care of myself as I know I frequently feel lack of enthusiasm to take care of myself as I know I should. I should. ASAS- R 8 In the past, I have changed some of my old habits to take better In the past, I have changed some of my old customs to take better care of my care of my health. health. ASAS- R 10 I regularly evaluate the effectiveness of the things I do to stay I regularly evaluate if the things I do to stay healthy are working. healthy. ASAS- R 11 In my daily activities, I rarely dedicate any time to care for my In my day-to-day life, I rarely dedicate any time to care for my health. health. Undecided *VPC1-first consensual version for Brazilian Portuguese; **VPF-final version for Brazilian Portuguese Acta Paul Enferm. 2014; 27(3):221-9. 225 Translation, adaptation and validation of a self-care scale for type 2 diabetes patients using insulin Table 1. Clinical and sociodemographic characteristics, test phase Clinical and sociodemographic characteristics n(%) Variation Interval Median Mean SD 18 - 94 64 58.6 16.4 556.75 Gender Female 83(55.3) Male 67(44.7) Age (years) <60 56(37.3) ≥60 94(62.7) Marital Status Married/living together 72(48.0) Single 39(26.0) Widowed 33(22.0) Divorced/separeted 6(4.0) Occupation Retired/pensioner 76(50.7) Active 48(32.0) Homemaker 20(13.3) Unemployed 1(0.7) Student 5(3.3) Education Level Illiterate 17(11.3) No schooling/can read and write 14(9.3) 1˫9 years of schooling 74(49.4) ≥ 9 years of schooling 45(30.0) Monthly family income (in minimum monthly wages*) 0 - 2,200.00 1,000.00 924.63 Time with DM (years) 1 - 41 13 10.5 8.78 Time of insulin use (years) 1 - 40 5 6.41 6.24 *value of monthly minimum wage at the time was 545.00 Brazilian reais; SD – Standard Deviation Table 2. Item correlation coefficient-total and values of Cronbach’s alpha (α) for the totality of items when each item was excluded from ASAS-R, test phase Item correlation coefficient-total Cronbach’s Alpha if item is excluded ASAS-R 1 0.32 0.71 ASAS-R 2 0.22 0.69 ASAS-R 3 0.32 0.71 ASAS-R 4 0.31 0.70 ASAS-R 5 0.46 0.70 ASAS-R 6 0.32 0.70 ASAS-R 7 0.69 0.66 ASAS-R 8 0.35 0.71 ASAS-R 9 0.19 0.73 ASAS-R 10 0.35 0.71 ASAS-R 11 0.41 0.70 ASAS-R 12 0.51 0.70 ASAS-R 13 -0.18 0.76 ASAS-R 14 0.54 0.69 ASAS-R 15 0.44 0.70 Item ASAS-R (α = 0,74) 226 Acta Paul Enferm. 2014; 27(3):221-9. The items’ internal consistency, obtained by Cronbach’s alpha, was 0.74. The values for the alpha of the totality of items suffered small alterations when each of the 15 items was excluded (Table 2). The replicability of the adapted scale, through test-retest and interobserver reliability analysis, confirmed ASAS-R’s stability (r=0.81; p<0.001) and equivalence (r=0.84; p<0.001). Analysis of convergent validity confirmed the hypothesis of inverse correlation between ASAS-R and DCS scores (r =-0.70; p<0.001). It also confirmed our hypothesis of positive correlation with the following domains of the Perceived Health Status instrument (physical and social aspects were excluded): functional capacity (r=0.38; p<0.01), vitality (r=0.49; p<0.01), emotional aspects (r=0.36; p<0.01), mental health (r=0.41; p<0.01) and general state of health (r=0.52; p<0.01). On the other hand, the hypothesis of positive correlation with the Social Support Scale (r=0.12; p 0.17) was not supported. It is important to highlight that 98% of the interviewees reported living with family members or other companions. Stacciarini TS, Pace AE Regarding discriminant construct validity, the group of patients with over nine years of schooling obtained higher scores for capacity for self-care than did the group with under 9 years of schooling (p 0.002); patients over 75 years old displayed lower scores on capacity for self-care when compared to those under 75 (p 0.026); and patients who self-apply insulin obtained higher scores on capacity for self-care compared to those who do not (p<0.001). Discussion Throughout the various phases of the translation and cultural adaptation process, we observed that the translator’s profiles resulted in differing word choices. Thus, since the items’ cultural and semantic equivalence would be prioritized in other phases, such as in the assessment by the committee of judges and semantic validation, we thought it pertinent to preserve the grammatical structure of the version closest to the original in its literary form, always observing and comparing the discrepancies and ambiguities between versions. At the end of this process, the adapted ASAS-R was analyzed for its reliability, replicability and validation using a group of 150 type 2 diabetes mellitus patients taking insulin. The number of participants was according to the recommended number in traditional psychometrics, which prescribes a minimum of five and a maximum of 10 respondents for each item on the instrument.(9) The items on the ASAS-R which presented ceiling or floor effects in the testing phase were: “I often lack the energy to take care of myself in the way that I know I should” (ASAS-R 4); “If I take a new medication, I obtain information about the side effects to better care for myself ” (ASAS-R 7); and “I am able to get the information I need, when my health is threatened” (ASAS-R 12). The answer choices on the other extreme of “totally disagree” were: “In my daily activities, I seldom take time to care for myself.” (ASAS-R 11); and “I seldom have time for myself ” (ASAS-R 14). This effect may have been influenced by: the sociodemographic characteristics of the sample, who were mostly elderly patients (62.7%) and retirees (50.7%) who had received less than 9 years of schooling (70.0%); time available time for self-care, since most are retired; limited reading comprehension; family participation in the decision-making process; and the easy access to information provided by the ESF unit’s working methodology. As an example, it is very likely that a retired person has plenty of time for self-care, thus they may have completely agreed with this statement. In the study by Sousa et al(4) the sample comprised 141 patients with DM taking insulin; the majority were married women with an average age of 48 years and a good income. However, in another of their studies,(6) the sample comprised 629 adults from the population in general; the majority were married women with an average age of 35, employed, and with a higher education degree. Based on our assessment that the characteristics of the studied group might have influenced the answer distribution, we chose not to exclude or reformulate such items; however, these effects might have influenced the results obtained when analyzing internal consistency and item correlation. Cronbach’s alpha for internal consistency was 0.74, lower than in the original revised version (α=0.89). (6) The present version presented the highest value found in all the literature, including studies which used the original version with 24 items (alpha values ranging from 0.59 to 0.80).(4,6) Although the values of total item correlation were lower compared to the original study,(6) most were moderate to strong in magnitude (r=0.31 to r=0.69), which makes for satisfactory results, when considering that the ideal value for initial validation studies must be higher than 0.30.(14) Regarding the modes of reliability assessment for the ASAS-R, test-retest and interobserver analysis were used. The results pointed to strong correlations of the analyses (r=0.81; p<0.001) e (r=0.84; p<0.001), respectively, suggesting that the adapted scale is reliable, for its properties are stable and equivalent. Acta Paul Enferm. 2014; 27(3):221-9. 227 Translation, adaptation and validation of a self-care scale for type 2 diabetes patients using insulin Among the scales used for measuring convergent validity,(4-6) we selected the versions which had already been adapted for Brazil, such as the Social Support Scale and the Depressive Cognition Scale. The Perceived Health Status instrument was used by other studies that used the original ASAS version with 24 items. Regarding convergent validity, the hypothesis of a correlation between capacity for self-care and social support (r=0.12; p 0.17) was not supported, despite knowing that the environmental factor “social support” influences an individual’s capacity for self-care(4,5) and is a strategy for increasing one’s engagement with self-care.(12) One variable that might have influenced this result was patients’ heightened perception about their access to emotional, affective and material support (98% of interviewees do not live alone). On the other hand, there was correlation between ASAS-R and DCS scores(r=-0.70; p<0.001) and also SF-36 scores. The personal factor “depression” can affect an individual’s capacity for selfcare and adequate health-promotion behaviors for preventing illness and engaging in self-care management, especially in the case of DM. It is one of the causes of treatment abandonment and, consequently, results in worsened glycemic control and increased risk of complications.(11) The correlation between capacity for self-care and perceived health was observed in the domains of functional capacity, physical and emotional aspects, pain, vitality and general state of health. There was no significant correlation between the social aspect domain and the total ASAS-R score. Regarding discriminant construct validity among distinct groups, statistically significant differences between age, education level and insulin self-application ability were observed. We based our hypotheses on Orem’s theoretical references, which state that intrinsic and extrinsic factors of basic conditioning, including age, education level and use of daily life resources to carry out activities, affect the development and maintenance of capacity for self-care. The hypothesis that capacity for self-care presents different characteristics among groups 228 Acta Paul Enferm. 2014; 27(3):221-9. of patients who self-apply insulin and those who do not is justified due to the fact that the evolution of DM, in addition to the senility process, act in favor of increasing the risk of the appearance of visual, motor and cognitive complications, problems which can interfere in one’s ability for insulin self-application and, consequently, in the capacity for self-care.(3,4,15,16) In this sense, the process undertaken resulted in a valid, reliable, replicable, comprehensible, brief and easily applicable scale. Thus, the present study contributes towards the Brazilian Unified Health System’s proposals for primary health care and health promotion, especially among DM patients. More evidence of this scale’s validity must be gathered in order to increase the confidence surrounding its usage. In addition, the scale should preferably be applied to general population samples to strengthen the results of the psychometric analysis and demonstrate the dimensionality of the factorial structure proposed by the authors of the original revised version, which was not the objective of the present study. Conclusion The Brazilian-Portuguese version of the ASAS-R, obtained after translation and adaptation with a group of insulin-taking type 2 diabetes mellitus patients, maintained conceptual, semantic and cultural equivalence, according to the original version. Regarding convergent validity, we confirmed correlations between capacity for selfcare, depression and perceived health, but not social support. In terms of discriminant validity, we observed significant differences between groups regarding age, education levels and insulin self-application. Collaborations Stacciarini TSG created the project, executed the research and wrote the article. Pace AE provided relevant critical reviews of intellectual content and obtained final approval for publication. Stacciarini TS, Pace AE References 1. Schmidt MI, Duncan BB, Silva GA, Menezes AM, Monteiro CA, Barreto SM, Chor D, Menezes PR. Doenças crônicas não transmissíveis no Brasil: carga e desafios atuais. The Lancet [Série Saúde no Brasil]. 2011: 61-73. 2. Haas LB, Maryniuk M, Beck J, Cox CE, Duker P, Edwards L, et al. National standards for diabetes self-management education and support. Diabetes Care. 2013; 36(Suppl 1):S100-8. 3. Stacciarini TS, Haas VJ, Pace AE. Fatores associados à autoaplicação da insulina nos usuários com diabetes mellitus acompanhados pela Estratégia Saúde da Família. Cad Saúde Pública. 2008; 24(6):314-22. 4. Sousa VD, Zauszniewski JA, Zeller RA, Neese JB. Factor Analysis of the appraisal of self-care agency scale in American adults with diabetes mellitus. Diabetes Educ. 2008; 34(1):98-108. 5. Sousa VD, Hartman SW, Miller EH, Carroll MA. New measures of diabetes self-care agency, diabetes self-efficacy and diabetes selfmanagement for insulin-treated individuals with type 2 diabetes. J.Clin Nurs. 2009; 18(9):1305-12. 6. Sousa VD, Zausniewski JA, Bergquist-Beringer S, Musil CM, Neese JB, Jaber, AF. Reliability, validity and factor structure of the Appraisal of Self Care Agency Scale- Revised (ASAS-R). J Eval Clin Pract. 2010;16(6):1031-40. 7. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self report measures. Spine. 2000;25(24):3186-91. 8. Ferrer M, Alonso J, Prieto L, Plaza V, Monsó E, Marrades R, Aguar MC, Khalaf A, Antó JM. Validity and reliability of the St George’s respiratory questionnaire after adaptation to a different language and culture: the Spanish example. Eur Respir J. 1996;(9):1160-66. 9. Pasquali L. Psicometria. Rev Esc Enferm USP. 2009; 43(Esp):992-9. 10.Deon KC, Santos MS, Reis RA, Fedadolli C, Bullinger M, Santos CB. Tradução e adaptação para o Brasil do DISABKIDS Atopic Dermatitis Module (ADM). Rev Esc Enferm USP. 2011; 45(2):450-7. 11.Sousa VD, Zauszniewski JA, Mendes IAC, Zanetti ML. Cross-cultural equivalence and psychometric properties of the portuguese version of the depressive cognition scale. J Nurs Meas. 2005; 13(2):87-99. 12.Griep RH, Chor D, Faerstein E, Werneck G, Lopes CS. Validade de construto de escala de apoio social do Medical Outcomes Study adaptada para o português no Estudo Pró-Saúde. Cad Saúde Pública. 2005;21(3):703-14. 13.Ciconelli RM, Ferraz MB, Santos W, Meinão I, Quaresma MR. Tradução para língua portuguesa e validação do questionário genérico de avaliação de qualidade de vida SF 36. Rev Bras Reumatol. 1999;39(3):143-50. 14.Fayers PM, Machin D. Quality of life. The assessment, analysis and interpretation of patient reported outcomes. 2nd ed. Chichester: John Wiley & Sons; 2007. 529p. 15. Stacciarini TS, Pace AE, Haas VJ. Insulin self-administration technique with disposable syringe among patients with diabetes mellitus followed by the Family Health Strategy. Rev Latinoam Enferm. 2009; 17(4):474-80. 16. Stacciarini TS, Caetano TS, Pace AE. Dose de insulina prescrita versus dose de insulina aspirada. Acta Paul Enferm. 2011; 24(6):789-93. Acta Paul Enferm. 2014; 27(3):221-9. 229 Original Article Quality of life related to the health of chronic renal failure patients on dialysis Qualidade de vida relacionada à saúde de pacientes renais crônicos em diálise Jéssica Maria Lopes1 Raiana Lídice Mor Fukushima1 Keika Inouye1 Sofia Cristina Iost Pavarini1 Fabiana de Souza Orlandi1 Keywords Renal dialysis; Nursing assessment; Chronic renal failure; Quality of life Descritores Diálise renal; Avaliação em enfermagem; Qualidade de vida; Insuficiência renal crônica Submitted December 19, 2013 Accepted May 5, 2014 Abstract Objective: To assess the quality of life related to the health of chronic renal failure patients on dialysis. Methods: Cross-sectional study with 101 chronic renal failure patients who had been under dialysis treatment for three months. The instruments used for research were: Instrument of Characterization of Subjects and the Kidney Disease Quality of Life-Short Form. A descriptive analysis was performed and the standard deviation was found; Cronbach’s alpha was used to assess the reliability of alpha values equal to or greater than 0.60. Results: The quality of life was proven to be compromised in the following aspects: “Physical Function (30.20), Work Situation (37.13) and Physical Functioning”. The best perceptions were: “Cognitive Function (89.31), Social Support (88.61) and Sexual Function (84.58)”. Conclusion: Quality of life related to the health of chronic renal failure patients on dialysis was more compromised in physical aspects. Resumo Objetivo: Avaliar a qualidade de vida relacionada a saúde de pacientes renais crônicos em diálise. Métodos: Estudo transversal com a inclusão de 101 pacientes renais crônicos com três meses de tratamento dialítico. Os instrumentos de pesquisa foram: Instrumento de Caracterização dos Sujeitos e do Kidney Disease Quality of Life- Short Form. Foi realizada análise descritiva e desvio padrão; coeficiente Alfa de Cronbach para verificar a confiabilidade para valores de alfa iguais ou superiores a 0,60. Resultados: A qualidade de vida mostrou-se comprometida nos domínios: “Função Física (30,20), Situação de Trabalho (37,13) e Funcionamento Físico”. As melhores percepções ocorreram: “Função Cognitiva (89,31), Suporte Social (88,61) e Função Sexual (84,58)”. Conclusão: A qualidade de vida relacionada a saúde de pacientes renais crônicos em diálise apresentou maior comprometimento nos domínios físicos. Corresponding author Fabiana de Souza Orlandi Washington Luis Highway, km 235, São Carlos, SP, Brazil. Zip Code: 13565-905 [email protected] DOI http://dx.doi.org/10.1590/19820194201400039 230 Acta Paul Enferm. 2014; 27(3):230-6. Universidade Federal de São Carlos, São Carlos, SP, Brasil. Conflicts of interest: there are no conflicts of interest to declare. 1 Lopes JM, Fukushima RL, Inouye K, Pavarini SC, Orlandi FS Introduction Chronic renal failure is considered to be a public health issue, and it consists of the slow, gradual and irreversible loss of renal function, resulting in failure of the kidneys to perform their basic functions.(1,2) The number of patients undergoing dialysis treatment has been growing over the years, from 42,695 cases in 2000 to 91,314 in 2011, hemodialysis being the most common form of treatment.(3) During the treatment stage, chronic renal failure patients may have their quality of life altered, as there is anxiety prior to and during treatment, loss of autonomy, difficulty of dealing with an irreversible and incurable disease, difficulty of going to a hospital daily or weekly, decrease in vitality levels, limitations in performing everyday activities, and frequent lack of support from relatives and friends, all of which damage the patient’s physical and mental health.(4) As renal failure develops, patients can show symptoms that affect their daily life. In more advanced stages, the impact on the functional state and quality of life becomes very clear. Renal replacement therapies, such as hemodialysis, partially rectify the symptoms experienced by patients and result in additional changes to their lifestyle, which can affect quality of life.(5) The objective of this study is to assess the quality of life related to the health of chronic renal failure patients on dialysis. Methods This is a cross-sectional study carried out in a specialized public health service located in the State of São Paulo, in the southeastern area of Brazil. The sample was composed of 101 chronic renal failure patients on hemodialysis, the inclusion criteria being: 1) Aged 18 or over; 2) Diagnosed with chronic renal failure diagnosis; 3) Being in hemodialysis treatment for at least 3 months. The research instruments were the Instrument of Characterization of Subjects and the Kidney Disease Quality of Life-Short Form (KDQOL-SF). The Instrument of Characterization of Subjects is composed of questions related to identification, sociodemographic data and clinical conditions. The KDQOL-SF was developed by the Working Group in 1997 (version 1.3) and validated in Brazil in 2003. The KDQOL-SF is applicable to patients under hemodialysis, aiming to measure the QVRS, in order to meet two essential properties: the assessment of the aspects that are important to the health condition and the integration of the information that came from specific and general domains, allowing for a thorough analysis. The score procedure is done through the KDQOL-SF measurement, and therefore is analyzed separately. Thus, there is not a unique value that results from the general assessment of quality of life related to health, but rather average scores for each aspect. This analysis enables identification of the actual problems related to patient health and which have an impact on quality of life.(6,7) The final score of each aspect varies within a range of 0 to 100, where the higher score reflects better quality of life.(6) Data from the KDQOL-SF were transferred to a review program produced and made available by the Working Group. The program also has Microsoft Excel® sheets, which automatically recode all of the data of the items with reverse scores and calculates the scores by item of each aspect. Data collected were transferred to a Microsoft Excel® sheet and the analyses were performed with the help of a statistics program: a) descriptive: frequency tables, with position figures (mean, median, minimum and maximum) and standard deviation; Cronbach’s alpha: evaluates the internal consistency of the KDQOL-SF. Reliability is considered good for alpha values equal to or greater than 0.60.(7) Acta Paul Enferm. 2014; 27(3):230-6. 231 Quality of life related to the health of chronic renal failure patients on dialysis The development of the study complied with national and international rules of ethics in human research. Table 1. Sociodemographic and Clinical features Variables n(%) Gender Female 32 (32) Male 69(68) Age group (yrs) Results The sociodemographic features found in this study are described in table 1. Out of 101 subjects participating in the study, 69 were male and 32 were female. Their age varied from 24 to 88 years; the age group with the greatest percentage of participants was 50 to 59, at 27%. According to the division by age group, 57 were adults and 44 were elderly. The prevalent ethnic group was white (n=50). Regarding marital status, the majority was married (n=56). As for schooling, most subjects had completed primary school (n=28). Table 1 shows that most subjects had wages ranging from 1.1 to 2 times minimum wage (30.8%) and were Catholics. We see that the most prevalent basic disease was systemic hypertension (59.4%). Regarding the use of medicine, 100% of individuals made use of it. In table 2, it is observed that the average age of the studied subjects was 56.4 (±14.44) years. As for the clinical variables, the average hemodialysis treatment period was 43.15 (±43.24) months. Concerning the laboratory tests, the average hematocrit and albumin levels were 32.78 (±15.03%) and 3.78 (±0.47g/dl) respectively. In table 3, the average scores of quality of life related to health are described. It was observed that the aspects that obtained lower scores were: “Physical Function (30.20), Work Situation (37.13) and Physical Functioning” (46.68). On the other hand, the aspects that obtained higher scores were: “Cognitive Function” (89.31), “Social Support” (88.61) and “Sexual Function” (84.58). Regarding the internal consistency of KDQOL-SF, most aspects obtained satisfactory Cronbanch’s alpha scores (≥ 0,60). 232 Acta Paul Enferm. 2014; 27(3):230-6. 18-29 4(4) 30-39 11(11) 40-49 14(14) 50-59 28(27) 60-69 25(25) 70-79 12(12) 80 or over 7(7) Color of skin White 50(49.5) Brown 31(30.7) Black 20(19.8) Marital status Married 56(55.5) Divorced 16(15.8) Widowed 13(12.8) Single 12(12) Other 4(3.9) Schooling None 7(6.9) Primary education incomplete 21(20.8) Primary education complete 28(27.7) Secondary education incomplete 20(19.8) Secondary education complete 16(16) Higher education complete 7(6.9) Higher education incomplete 2(1.9) Income* Equal to or lower than 1MW** 25(26.6) From 1.1 to 2 MW 29(30.8) From 2.1 to 3 MW 24(25.5) More than 3 MW 16(17.1) Religion Catholic 68(67) Evangelical 21(22) Spiritist 3(3) Jehovah’s Witness 2(2) None 7(6) Basic disease Hypertension 60(59.4) Type 2 Diabetes mellitus 27(26.7) Glomerular nefhritis 4(4) Genetic/hereditary 3(3) Other 7(6,9) Use of medicine Yes 101(100) No Total *Seven subjects were unable to provide their incomes; **MW=Minimum wage 0(0) 101 Lopes JM, Fukushima RL, Inouye K, Pavarini SC, Orlandi FS Table 2. Length of hemodialysis and laboratory exam results Variable n Mean (Sd)** Median Minimum Maximum Age (years) 101 56.40(14.44) 58.00 24.00 88.00 Time of Hd* (months) 101 43.15(43.24) 36.00 3.00 240.00 Hematocrit (%) 101 32.78(5.03) 33.30 19.20 47.40 Albumin (g/dl) 101 3.78(0.47) 3.80 2.10 6.90 *Hd = Hemodialysis; *Sd = Standard deviation Table 3. Quality of life related to health Aspects Mean (±Sd)** Median Variation Cronbach’s alpha Symptoms/problems 76.09(±13.06) 79.17 31-100 0.72 Effects of renal failure 68.01(±14.83) 68.75 31-100 0.60 Disease burden 51.36(±23.13) 50.00 0-100 0.63 Work situation 37.13(±28.68) 50.00 0-100 0.32 Cognitive function 89.31(±13.57) 93.33 47-100 0.60 Quality of social interaction 82.97(±12,45) 86.67 33-93 0.42 Sexual function 84.58(±20.94) 93.75 25-100 0.79 Sleep 66.73(±17.27) 70.00 20-95 0.70 Social support 88.61(±20.13) 100.00 17-700 0.71 Incentive by the dialysis staff 79.83(±22.77) 75.00 0-100 0.76 Satisfação do paciente 66.83(±20.61) 66.67 0-100 - Patient’s satisfaction 46.68(±31.39) 45.00 10-100 0.60 Physical functioning 30.20(±35.59) 25.00 15-90 0.92 Pain 69.13(±32.43) 80.00 32-88 0.78 General state of health 49.36(±16.70) 45.00 0-100 0.92 Emotional well-being 69.98(±14.08) 72,00 0-100 0.65 Emotional function 74.59(±31.67) 100,00 10-90 0.57 Social function 55.45(±26.01) 62.50 13-54 0.67 Energy/Fatigue 60.50(±18.51) 60.00 25-61 0.74 Discussion The limitations of the results of this study are associated with the cross-sectional pattern, which does not allow for the establishment of cause and effect relationships. Patients with chronic renal failure under hemodialysis treatment live with an incurable disease that needs long-term treatment. Besides, the evolution of the disease and its complications lead to limitations and changes in their quality of life and that of their relatives and friends. Out of the 101 studied subjects, the majority of was male (68%). The Brazilian Society of Nephrology confirmed in the 2011 Census that approximately 57% of chronic renal failure patients were male, whereas 42% were female.(3) Observational studies have pointed out the prevalence of the disease in male subjects.(8-11) In other studies, the prevalence was in female subjects.(12-14) Regarding the age groups, despite the high percentage of elderly people (42%), the most prevalent age group was 50 to 59. This finding was also observed in another study, where the prevalent age group was 40 to 60.(14) As for the color of skin, white was prevalent, similar to other studies.(8,10) Concerning marital status, it was observed that most subjects were married (55.5%). Similar results were found in several studies.(8-10,15,16) Regarding religious belief, most individuals declared themselves as Catholics (67,0%). This finding conforms to other studies which reported that the subjects were Catholic in 57% and 85% of cases.(17,18) As for schooling, it was observed that the prevalence was of subjects who had completed primary school (27.7%), similar to other studies in which 63.2% and 56.4% of individuals had the same education level.(6,19) Concerning income, most subjects had up to two times the minimum wage (30.8%). In other studies found in the literature, results were consistent with the present one, as 34% and 46% had a minimum wage or less.(15,17) As for clinical features, the prevalence of systemic hypertension was observed (59.4%) as a basic disease, followed by diabetes mellitus (26.7%). This finding conforms to the results of another study that observed that their subjects had diabetes mellitus and hypertension as a basic renal disease in more than 71% of the total cases.(10) In this study, the average hemodialysis treatment time was approximately 43 months (which correActa Paul Enferm. 2014; 27(3):230-6. 233 Quality of life related to the health of chronic renal failure patients on dialysis sponds to 3.6 years). Similar results were found in the literature, where the average treatment period was 40 months.(11) Regarding albumin, the average score of participants was 3.78 (±0.47) g/dl. Albumin is the most common marker used to evaluate the nutritional status of hemodialysis patients. The recommended value for albumin is above 3.5 mg/dl, therefore we can consider the results of this study within the normal range.(3,20) There are publications that found albumin levels above the average (4.11mg/dl and 4.2g/dl, respectively).(11,12) Another clinical variable that was analyzed was the laboratory test result of hematocrit, used as an anemia marker, which has a reference value of 33%(21) It is worth mentioning that many studies indicate that anemia affects the quality of life related to the health of chronic renal failure patients. There is also evidence in the literature that indicates that hemodialysis patients show significant improvement in their survival when normal hematocrit is reached.(22) In our study, the average value of hematocrit obtained was (32.78%), which is close to the minimum expected value. A research study carried out in two Spanish hospitals with 53 patients undergoing peritoneal dialysis found an average value of 33.46%.(13) As for the drugs, all participants made use of them. Another study found an average of 4.1 drugs per day for each hemodialysis patient.(16) In the assessment of quality of life related to health, high average scores were obtained in the aspects “Cognitive Function” (89.31), “Social Support” (88.61), “Sexual Function” (84.58) and “Quality of Social Interaction” (82.97). The highest average score was for “Cognitive Function” (89.31). Despite having obtained this result, it is worth mentioning that chronic renal failure patients are a group at risk for cognitive decline. In that sense, even with good performance in this aspect, periodic evaluation of cognitive function is necessary, as there are many risk factors for cognitive impairment.(23) The second aspect with the high performance was “Social Support” (88.61). The importance of social support to the individual is considerable, as the participation of family in care is an essential resource 234 Acta Paul Enferm. 2014; 27(3):230-6. for improving better acceptance of the disease and treatment by patients. Other works also show high average scores of 79.1, 88.2 and 81.1.(6,13,15) Another aspect that presented high average scores in our study was “Sexual Function” (84.58), and there are other studies with similar results.(6,15) However, a decrease in the levels of quality of life was observed due to erectile dysfunction, which is a prevalent condition in chronic renal failure patients. Therefore, the results in this aspect must be analyzed cautiously, as the sample of patients who had sexual intercourse up to three weeks before the test was composed of 30 individuals, which is considered low.(24) The lowest average scores of quality of life related to health were: “Physical Function (30.20), Work Situation (37.13) and Physical Functioning” (46.68). In this context, the results suggest that the set of symptoms of the diseases, along with the patients’ everyday life factors, have a negative impact on hemodialysis patients. Worthy of note is that the “Physical Aspect” may be the most affected in the perception of these patients.(15) In our study, the second most affected aspect was “Work Situation.” Work is a basic condition for human emancipation and is part of each person’s identity; therefore, it becomes one of the most precious values of human beings. As a result of the disease and treatment, patients often need to stop working, and this has an impact on quality of life. To stop working or to reduce the workload is an aspect that is opposed to the lifestyle the individual had before, so it has a negative impact on quality of life.(14) The third aspect with a lower average score was “Physical Functioning,” showing that there is a decrease in the ability to perform everyday activities or work. Some studies have suggested the implementation of a program of regular exercise for this group.(25) Conclusion Quality of life related to the health of chronic renal failure patients on dialysis showed a better percep- Lopes JM, Fukushima RL, Inouye K, Pavarini SC, Orlandi FS tion of the aspects “Cognitive Function,” “Social Support,” “Sexual Function” and “Quality of Social Interaction”; and lower scores in “Physical Function,” “Work Situation,” “Physical Functioning” and “General State of Health”. Acknowledgments Research done with the support of the Research Support Foundation of São Paulo (FAPESP, as per its acronym in Portuguese), process number 2012/19453-2. Collaborations Lopes JM and Fukushima RLM contributed in the execution of the research, planning, analysis and interpretation of data, writing of the article, and final approval of the published version. Inouye K and Pavarini SCI contributed in the analysis and interpretation of data, writing of the article and final approval of the published version. Orlandi FS participated in the conception of the project, planning, analysis and interpretation of data, writing of the article, critical review of the content and final approval of the published version. 8. Bass A, Ahmed SB, Klarenbach S, Culleton B, Hemmelgarn BR, Manns, B. The impact of nocturnal hemodialysis on sexual function. BMC Neprol. 2012; 13 (67):13-67. 9. Biavo BM, Tzanno-Martins C, AraujoML, Ribeiro MM, Sachs A, Uezima CB, Draibe SA, Rodrigues, CI, Barros EJ. Aspectos nutricionais e epidemiológicos de pacientes com doença renal crônica submetidos a tratamento hemodialítico no Brasil, 2010. J Bras Nefrol. 2012;34(3):206-15. 10.Bignotto LH, Kallas ME, Djouki RJ, SassamiI MM, Voss GO, Soto CL, Fratini F, Medeiros FS. Achados eletrocardiográficos em pacientes com doença renal crônica em hemodiálise. J Bras Nefrol, 2012;34(3):23542. 11. Guerreiro VG, Alvarado OS, Espina MC. Qualidade de vida de pessoas em hemodiálise crônica: relação com variáveis sociodemográficas, médico-clínicas e de laboratório. Rev Latinoam Enferm. 2012;20(5):19. 12.Barberato, SH, Bucharles SG, Souza AM, Costantini CO, Constantini CR, Pecoits-Filho. R. Assiciação entre marcadores de inflamação e aumento do átrio esquerdo em pacientes em hemodiálise. Arq Bras Cardiol, 2013;100(2):41-6. 13.Varela L, Vázquez MI, Bolanos L, Alonso, R. Predictores psicológicos de La calidade de vida relacionada con La salud em pacientes em tratamiento de diálisis peritoneal. Rev Nefrol. 2011;31(1):97-106. 14. Grasselli CS, Chaves EC, Simao, TP, Botelho, PB, Silva RR. Avaliação da qualidade de vida dos pacientes submetidos à hemodiálise. Rev Bras Clin Med. 2012;10(6):503-7. 15.Braga SF, Peixoto, SV, Gomes IC, Acurcio, FA, Andrade EI, Cherchiglia ML. Fatores associados com qualidade de vida relacionada à saúde de idosos em hemodiálise. Rev Saúde Pública. 2011;45(6):1127-113. 16. Sgnaolin V, Prado AE, Figueiredo L. Adesão ao tratamento farmacológico de pacientes em hemodiálise. J Bras Nefrol. 2012;32(2):109-16. References 17.Medeiros MCWC, Sá MPC. Adesão dos portadores de doença renal crônica ao tratamento conservador. Rev Rene. 2011;12(1):65-72. 1. Bastos MG, Kirsztajn, GM. Doença renal crônica: importância do diagnóstico precoce, encaminhamento imediato e abordagem interdisciplinar estruturada para melhora do desfecho em pacientes ainda não submetidos à diálise. J Bras Nefrol. 2011;33(1):93108. 18.Valcanti CC, Chaves EC, Mesquita AC, Nogueira DA, Carvalho EC. Coping religioso/espiritual em pessoas com doença renal crônica em tratamento hemodialítico. Rev Esc Enferm USP. 2012;46(4):838-45. 2. Frota MA, Machado JC, Martins MC, Vasconcellos VM, Landin, FL. Qualidade de vida da criança com insuficiência renal crônica. Rev Esc Anna Nery. 2010;14(3):527-33. 3. Sesso RC, Lopes AA, Thomé FS, Lugon JR, Watanabe Y, Santos DR, Diálise Crônica no Brasil - Relatório do Censo Brasileiro de Diálise. J Bras Nefrol. 2012;34(3):272-7. 4. Terra FS. Avaliação da qualidade de vida do paciente renal crônico submetido à hemodiálise e sua adesão ao tratamento farmacológico de uso diário. Rev Bras Clin Med. 2010;8(2):119-24. 5. Poppe C, Crombez, G, Hanoulle I, Vogelaers D, Petrovic M. Improving quality of life in patients with chronic kidney disease. Nephrol Dial Transplant. 2013;28(1):116-21. 6. Silva AS, Coelho DM, Diniz GC. Qualidade de vida dos pacientes com insuficiência renal crônica submetidos à hemodiálise em um hospital público de Betim, Minas Gerais. Sinopse Múltipla. 2012; 1(2): 103-13. 7. Hair JF, Anderson RE, Tathan RL, Black WC. Análise multivariada de dados. 5a ed. Porto Alegre: Bookman; 2007. 593 p. 19.Grincekov FR, Fernandes N, Chaoubah A, Bastos K, Quereshi AR, Pecoits-Filho R, Divino FIlho, JC, Bastos MC. Fatores associados à qualidade de vida de pacientes incidentes em diálise peritoneal no Brasil (BRAZPD). J Bras Nefrol, 2011;33(31): 38-44. 20.Santos FR, Figueiras MS, Chaobah A, Bastos MG, Paula RB. Efeitos da abordagem interdisciplinar na qualidade de vida e em parâmetros laboratoriais de pacientes com doença renal crônica. Rev Psiquiatr Clín.. 2008;35(3):87-95. 21.Morsch CM, Gonçalves LF, Barros E. Health-related quality of life among hemodialysis patients – relationship with clinical indicators, morbidity and mortality. J Clin Nurs. 2006;15(4):498-504. 22.Coyne DW. The health-related quality of life was not improved by targeting higher hemoglobin in the Normal Hematocrit Trial. Kidney Int. 2012;82(2):235-241. 23.Condé SA, Fernandes N, Santos FR, Chaouab A, Mota MM, Bastos MG. Declínio cognitivo, depressão e qualidade de vida em pacientes de diferentes estágios da doença renal crônica. J Bras Nefrol. 2010;32(3):242-8. Acta Paul Enferm. 2014; 27(3):230-6. 235 Quality of life related to the health of chronic renal failure patients on dialysis 24. Nora R, Zambone GS, Fácio Junior FN. Avaliação da qualidade de vida e disfunções sexuais em pacientes com insuficiência renal crônica em tratamento dialítico em hospital. Arq Cienc Saúde. 2009;6(2):72-5. 236 Acta Paul Enferm. 2014; 27(3):230-6. 25.Nery RM, ZaniniI M. Efeitos de um programa de 12 semanas de exercícios físicos sobre a capacidade funcional e a qualidade de vida de pacientes com doença renal crônica em hemodiálise. J Bras Nefrol. 2009;31(2):151-3. Original Article Social and clinical factors causing mobility limitations in the elderly Fatores sociais e clínicos que causam limitação da mobilidade de idosos Jorge Wilker Bezerra Clares1 Maria Célia de Freitas1 Cíntia Lira Borges1 Keywords Aged; Mobility limitation; Geriatric nursing; Nursing in community health; Primary care nursing Descritores Idoso; Limitação da mobilidade; Enfermagem geriátrica; Enfermagem em saúde comunitária; Enfermagem de atenção primária Submitted December 20, 2013 Accepted May 5, 2014 Abstract Objective: To investigate the association between physical mobility demands and social and clinical variables of the elderly living in the community. Methods: This was a cross-sectional study including 52 elderly community residents. The research instrument was constructed based on the theory of Virginia Henderson. Data were analyzed using descriptive statistics and the chi-square or Fisher exact test, with a significance level of 0.05. Results: The mean age was 72.6 (± 8.6) years, 69.2% were female. There was a prevalence of physical mobility demands, with significant statistical associations with significant statistical associations with social and clinical variables. Conclusion: Physical mobility was influenced by social and clinical characteristics of the elderly in the community. Resumo Objetivo: Investigar a associação entre demandas na mobilidade física e variáveis sociais e clínicas de idosos que vivem em comunidade. Métodos: Estudo transversal com a inclusão de 52 idosos residentes em comunidade. O instrumento de pesquisa foi construído com base na teooria de Virginia Henderson. Os dados foram analisados através da estatística descritiva e do teste do Qui-Quadrado ou exato de Fisher, com nível de significância 0,05. Resultados: A média de idade foi de 72,6 (±8,6) anos, 69,2% eram do sexo feminino. Houve prevalência de demandas da mobilidade física, com associações estatísticas significativas com as variáveis sociais e clínicas. Conclusão: A mobilidade física sofre influência das características sociais e clínicas em idosos da comunidade. Corresponding author Jorge Wilker Bezerra Clares Paranjana Avenue, 1700, Campus do Itaperi, Fortaleza, CE, Brazil. Zip Code: 60740000 [email protected] DOI http://dx.doi.org/10.1590/19820194201400040 Universidade Estadual do Ceará, Fortaleza, CE, Brazil. Conflicts of interest: no conflicts of interest to declare. 1 Acta Paul Enferm. 2014; 27(3):237-42. 237 Social and clinical factors causing mobility limitations in the elderly Introduction The aging of the population has drawn attention to the health conditions of the elderly, since this phenomenon is accompanied by higher rates of morbidity.(1) These changes, and their consequent functional limitations and disabilities, lead to an increased risk for disorders of physical mobility that can compromise the autonomy and independence of these subjects.(2) During the process of physiological aging, changes such as loss of muscle mass and reduction in strength and muscle function, joint stiffness and reduced range of motion, alterations in gait and in balance may significantly compromise the physical mobility of the elderly, predisposing them to falls, pain and functional disability.(3) It is noteworthy that several risk factors may be associated with mobility limitations in the elderly, and these can be individual, social, environmental and organizational.(4) In the United States, prevalence estimates suggest that physical mobility limitation is a significant problem for many elderly and is associated with several potentially modifiable characteristics, such as social situation, health conditions, and lifestyle.(5) In India, about 10% of the elderly population suffers with mobility limitations, and lives in a situation of great social vulnerability.(6) With the aging of the population worldwide, the production of evidence-based knowledge becomes of fundamental importance, in order to guarantee the sustainability of societies and quality of life of elderly people.(7) However, there is a shortage of studies in the Brazilian literature about the relationship between living conditions and health and the physical mobility of the elderly, demonstrating that these aspects have received little attention in the country. Knowing the different factors that affect physical mobility in this population will help to identify approaches for the planning of impactful actions, focusing on local needs, and the implementation of existing public policies, supporting the prevention of disability and dependence, and the promotion of active aging. This fact has raised questions that elucidated the conduct of this research, which aimed 238 Acta Paul Enferm. 2014; 27(3):237-42. to investigate the association between physical mobility demands and social and clinical variables in community-dwelling elderly. Methods This was a cross-sectional study conducted within a territory that covered two micro-areas of a Family Health Center in Fortaleza, in the northeastern region of Brazil, where the health courses of a public university developed teaching, research and extension activities. Participants in the research included people 60 years of age or older, of both sexes, who resided in the previously selected micro-areas, and who were in physical and mental condition to respond to the questions. Elderly people who were not found to be at home after three attempts to visit were excluded. Of the total of 61 elderly residents in these micro-areas, identified from the registration completed by community health workers, 52 met the requirements, composing the final sample. A questionnaire containing closed-ended questions, with its organization and structure based on the nursing theory of Virginia Henderson, was developed for data collection.(8) In this study, questions related to the need to move and maintain proper posture were analyzed, according to that theory, whose issues addressed items relating to the presence of difficulties in moving, joint stiffness, pain with movement, engaging in regular physical activity, risk for falls, and the need for help in order to move. Social and clinical characteristics studied were: age, sex, marital status, education, retirement, family income, presence of comorbidities, medication use, smoking, alcohol consumption and engagement in physical activity. In relationship to marital status, all those who reported being single, divorced or widowed were considered to be without a partner, and those who mentioned being married or living in a consensual union, were considered as having a partner. The age category was divided into three age ranges. With regard to education, those who could only sign their names were considered illiterate, and those who Clares JW, Freitas MC, Borges CL could read and write as literate. The income category had two divisions (up to three times the minimum wage. and more than three times the minimum wage). Data collection took place at the homes of the elderly, in the months of May and June of 2011. Results were processed and tabulated using the Statistical Package for the Social Sciences, version 17.0. For data processing, descriptive statistics, absolute frequency and percentage tables were used. Either the chi-square test or Fisher’s exact test was used for associations between categorical variables on the occurrence of values expected below five, in two by two tables. A significance level of 0.05 was adopted. The study followed the national and international standards of ethics in research involving human beings. Results There were 52 elderly included; their mean age was 72.6 (±8.6) years, ranging between 60 to 92 years. In table 1, it can be seen that the female gender(69.2%), elderly without a partner (51.9%), illiterate (88.5%), retired (69.2%) and those with income up to three times the minimum wage (96.2%) predominated. The main demands related to the need to move and maintain proper posture identified in the elderly were: difficulties in moving, 22 (42.3%); joint stiffness, 31 (59.6%); pain with movement, 30 (57.7%); no physical activity, 37 (71.1%); risk for falls, 35 (67.3%). Despite these problems, only three individuals (5.8%) were using locomotion aids - cane, and nine (17.3%) recognized the need for help to move and maintain proper posture. Regarding clinical characteristics, the most frequent comorbidities were: arterial hypertension, 25 (48.1%); osteoporosis, 18 (34.2%); diabetes, 10 (19.2%); gastritis, 8 (15.4%); and, urinary incontinence, 8 (15.3%). Other diseases were cited with lower frequencies: rheumatism, arthritis, arthrosis, depression, heart failure, chronic renal failure, Parkinson’s disease and Alzheimer’s disease. Associations between physical mobility demands and social and clinical variables of the participants in this study are shown in table 1. Table 1. Social and clinical variables and demands for the need to move and to maintain proper posture Variables n(%) Difficulties in moving Joint stiffness 16(30.8) 36(69.2) 0.018 0.261 20(38.5) 19(36.5) 13(25.0) 0.103 25(48.1) 27(51.9) p-value* Risk for falls Help with locomotion 0.198 0.030 <0.001 0.046 0.007 0.021 0.273 0.112 0.298 0.122 0.183 0.002 0.037 0.283 0.326 46(88.5) 06(11.5) 0.183 0.021 0.028 0.059 <0.001 0.118 36(69.2) 16(30.8) 0.018 0.261 0.198 0.030 <0.001 0.046 50(96.2) 02(3.8) 0.099 0.236 0.099 <0.001 0.092 0.288 37(71.2) 15(28.8) 0.032 <0.001 0.307 0.069 0.230 0.164 37(71.2) 15(28.8) 0.064 <0.001 0.307 <0.001 0.056 0.465 Pain with movement Help to move Gender Male Female Age 60-69 70-79 >80 Marital status With partner Without partner Education Illiterate Literate Retired Yes No Income (in MW**) Until 3 >3 Morbidity Yes No Medication Yes No Continue... Acta Paul Enferm. 2014; 27(3):237-42. 239 Social and clinical factors causing mobility limitations in the elderly Continuation Variables n(%) Difficulties in moving Joint stiffness 33(63.5) 19(36.5) 0.108 0.012 11(21.2) 41(78.8) 0.058 15(28.8) 37(71.2) 0.032 p-value* Risk for falls Help with locomotion 0.136 <0.001 <0.001 0.318 0.079 0.108 0.253 0.038 0.029 <0.001 <0.001 0.034 0.020 <0.001 Pain with movement Help to move Smoking Yes No Alcoholism Yes No Physical Activity Yes No * p-value refers to the chi-square test or Fisher’s exact test; ** The minimum wage (MW) of R$ 545.00 was used, considering the base year, 2011; n = 52 Discussion The limits of the results of this study refer to its cross-sectional design, which does not permit the establishment of relationships of cause and effect. On the other hand, the implication for nursing refers to the minimizing of risks to which the elderly are exposed, through the knowledge of the factors associated with their limitations in physical mobility. The predominance of females in the population investigated, as expected in relationship to the demographic composition of the elderly, due to the greater longevity of women, was similar to results found in other studies.(1,3,9) The feminization of old age is consistent, in part, with the prevalence of disorders of mobility among the elderly. The imbalance of calcium reabsorption, the constant demineralization of bone mass and density, which results in higher porosity and fragility of bone tissue, which can cause pain and allow the occurrence of fractures, with increased risk for limitations in physical mobility, is observed during the aging process in women with menopausal estrogen suppression.(10,11) The females also showed a statistically significant difference in the risk for falls (p=0.030). Studies indicate that being female is one of the major factors associated with increased risk for falls.(12) This may be related to greater loss of bone and muscle mass, in addition to the multiple tasks that women perform at home, leading them to a greater tendency of falling.(13) Age was associated with mobility problems among the elderly, with statistically significant dif- 240 Acta Paul Enferm. 2014; 27(3):237-42. ferences in joint stiffness (p=0.007) and pain with movement (p=0.021), with a prevalence of changes in the age group above 70 years old. Studies reveal that mobility limitations are, in part, related to the normal aging process, due to loss of muscle mass and bone density and to the articular wear, accentuated beginning at 70 years of age.(5) Marital status also seemed to have an influence on mobility limitations. A study conducted in five European countries (Finland, Netherlands, Germany, Hungary and Italy) found that elderly people without a partner are more likely to report greater difficulties related to the need to move.(14) Relating to education, the illiterate elderly had higher physical mobility demands. Those with lower instructional levels, associated with unfavorable socioeconomic and cultural factors, may have difficulty acquiring information and having awareness about the importance of health care throughout life, the need for adherence to treatment, and maintenance of healthy lifestyles, indirectly contributing to the occurrence of mobility disorders.(15) In this context, family health teams need to develop health promotion actions and prevention of complications, considering the low economic and educational levels of the elderly population. Such actions will need to be appropriate to the socio-cultural universe of this group, increasing the incentive for self-care. Retirement was also related to impaired physical mobility in this study. One possible justification for this relationship corroborated the results of a population-based study conducted in England with 1,693 workers, aged 50 years or more, which found that mobility limitations and musculoskeletal pain Clares JW, Freitas MC, Borges CL were predictors of early retirement.(16) On the other hand, the losses resulting from the withdrawal from work activities, with a reduction in work income, may be determinants of functional impairment, manifested by the adoption of sedentary attitudes, making the person vulnerable to diseases due to an unhealthy lifestyle,(17) such as mobility problems. However, the cross-sectional design used in this study did not allow the establishment of what was a cause and what was a consequence, between impaired physical mobility and retirement. The presence of comorbidities may be a risk factor associated with mobility limitations in the elderly, resulting in loss of functional capacity.(5) Thus, it may explain the high number of elderly people who have physical mobility demands associated with health problems. A majority of the elderly (71.2%) used medications, and this variable was significantly associated with joint stiffness (p = 0.000) and the risk for falls (p = 0.000). It is noteworthy that, although not verifying other statistically significant relationships, physical mobility demands among the elderly who were using continuous medications prevailed. The increase in the use of medications among the elderly was due to the higher prevalence of chronic diseases and the sequelae that accompanied advancing age.(18) The more medications the elderly ingest, the greater the risk of interaction between the medications, in addition to potentiation of their side effects. Therefore, the medical prescriptions for the elderly should be made carefully,(19) as well as the observation of the occurrence of their effects on mobility. Lifestyle and health behaviors were important risk factors for mobility limitations. Corroborating data from this research, studies show that a sedentary lifestyle, smoking and alcohol consumption were significantly associated with mobility limitations.(4,5) In the promotion of health, professionals should develop strategies to encourage the population to adopt a healthy lifestyle, particularly physical activity. This practice provides increased endurance and muscle strength, improves balance, prevents the loss of bone mass, as well as leading to improvements in self-efficacy, cognitive performance, recent memory, decrease in depressive symptoms, and an increase in social networks, contributing, therefore, significantly to the improvement of the quality of life.(20) Nevertheless, a challenge to incorporate regular physical activity into the daily lives of the elderly was demonstrated. National and international studies demonstrate that the proportion of elderly who practice physical activity remains low, despite recognizing the benefits of this practice and considering it to be a desirable behavior for the maintenance of good health.(9,21) Corroborating these data, it is emphasized that 71.2% of the elderly did not perform regular physical activity, which was statistically associated with all the demands of the need to move and maintain proper posture, according to the adopted theoretical approach. The reduction in activities is an indicator of frailty, contributing to the decline in functional capacity. Thus, the practice of physical activities by the elderly is of fundamental importance for the preservation of mobility and, consequently, for the maintenance of independence and autonomy. Changes in mobility must be taken into account during the assessment of health of the elderly, constituting important markers that could subsidize preventive actions of disability and dependency in old age. Conclusion The results showed that the physical mobility demands in community-dwelling elderly suffered a significant influence of social and clinical characteristics. Collaborations Clares JWB; Borges CL and Freitas MC contributed to the design and development of the research, data interpretation, writing, critical review of the relevant intellectual content, and final approval of the version to be published. References 1. Rodrigues RA, Scudeller PG, Pedrazzi EC, Schiavetto FV, Lange C. Morbidity and interference in seniors’ functional ability. Acta Paul Enferm. 2008;21(4):643-8. Acta Paul Enferm. 2014; 27(3):237-42. 241 Social and clinical factors causing mobility limitations in the elderly 2. Cleaver S, Hunter D, Ouellette-Kuntz H. 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Original Article Care practices for patient safety in an intensive care unit Práticas assistenciais para segurança do paciente em unidade de terapia intensiva Taís Pagliuco Barbosa1 Graziella Artuzi Arantes de Oliveira2 Mariana Neves de Araujo Lopes2 Nádia Antonia Aparecida Poletti2 Lúcia Marinilza Beccaria2 Keywords Nursing care; Nursing service, hospital; Nursing, practical; Patient safety; Intensive care unit Descritores Cuidados de enfermagem; Serviço hospitalar de enfermagem; Enfermagem prática; Segurança do paciente; Unidade de terapia intensiva Submitted January 6, 2014 Accepted 26 May 2014 Abstract Objective: To investigate good nursing care practices for patient safety in an intensive care unit. Methods: Descriptive study using a checklist with 19 items on hygiene/comfort, patient identification/falls and hospital infection. Four hundred fifty records were analyzed through G test of independence with Williams correction. Results: Altogether, good care practices are delivered with an index above 90%, exception for position changing, limb restraints kept clean, and ventilator circuit. Conclusion: Good nursing care practices for patient safety were performed differently based on work shifts. Resumo Objetivo: Verificar as boas práticas assistenciais de enfermagem para segurança do paciente em unidade de terapia intensiva. Métodos: Pesquisa descritiva, utilizando um checklist com 19 itens sobre higiene/conforto, identificação do paciente/queda e infecção hospitalar. Foram analisadas 450 verificações por meio do Teste G de independência com a correção de Williams. Resultados: Em conjunto, as boas práticas estão sendo realizadas com índice acima de 90%, com exceção da mudança de decúbito, restrições de membros limpas e circuito do ventilador. Conclusão: As boas práticas assistenciais de enfermagem para a segurança do paciente foram realizadas, com diversidade conforme o turno de trabalho. Corresponding author Taís Pagliuco Barbosa Brigadeiro Faria Lima Avenue, 5544, São José do Rio Preto, SP, Brazil. Zip Code: 15090-000 [email protected] DOI http://dx.doi.org/10.1590/19820194201400041 Hospital de Base de São José do Rio Preto, São José do Rio Preto, SP, Brazil. Faculdade de Medicina de São José do Rio Preto, São José do Rio Preto, SP, Brazil. Conflicts of interest: none to declare. 1 2 Acta Paul Enferm. 2014; 27(3):243-8. 243 Care practices for patient safety in an intensive care unit Introduction The essence of intensive care nursing is neither in the environment nor in the special devices, but in the decision-making processes based on the understanding of patients’ physiological and psychological conditions, with an emphasis on safe care.(1,2) The occurrence of care-related iatrogenic events endangers patients’ lives and has gained nurses’ attention in order to ensure minimal risk care.(1) Investigations on safe practices concern nurses because research still does not indicate a specific approach to the challenges of safety in nursing.(3) Healthcare free from risks and failures is a goal to be reached by health professionals and a commitment of professional education.(4) It is not different for the nursing team, since errors may occur that require immediate nursing actions in order to correct them, a situation that inevitably creates occupational stress.(5) Nurses working over 12.5 consecutive hours are more prone to error, especially at the end of the work shift and when performing multiple tasks.(6) Professionals who work beyond the time period mentioned are more exposed to the risk of error, and the longer the shift the greater the number of accidents.(7) In the intensive care unit, where patients’ clinical conditions range between narrow limits of normality/abnormality, where small organic changes can lead to severe impairment of body functions, the risk is greater.(2,8) The occurrence of errors is not only undesirable, but also harmful, thereby the issue of care safety and the context in which care is delivered is inevitably related to the assessment of health services.(9) Nursing work in the intensive care unit is described as stressful, wearing, fatiguing and overloading, especially regarding the working hours and the environment.(10,11) Patient safety is related to changes in the work process, i.e., the way humans produce and reproduce their existence, interfering with the way that nurses perform their daily work.(3,12) These professionals aim to organize nursing work and human resources, with the purpose of creating and implementing appropriate conditions for patient care. 244 Acta Paul Enferm. 2014; 27(3):243-8. Comprehensive care refers to a mode of nursing work organization, in which a worker provides all nursing care to a patient or group of patients; however it does not ensure integration of nursing work alone, as pointed out by a study at a teaching hospital of Santa Catarina. Attention to the complexity of care also requires workers’ participation in care planning, aimed at patient safety.(9) Care evaluation is an important tool in the control of work processes in healthcare.(13) In the intensive care unit, the expectation is to ensure the best result within patients’ clinical conditions and severity, with the lowest possible rates of procedure-related complications.(14,15) Errors represent a sad healthcare reality with serious consequences for patients, professionals and hospital organizations. The nursing team must have a magnified view of patients, their security processes and systems, mainly to guarantee security and quality of the process under their responsibility, seeking information about the flow of their activities, about issues with the environment and human resources, as well as knowledge about medications, medication interactions, etc., contributing to the efficient, responsible and safe accomplishment of nursing care.(15) Because of the complexity of nursing care, its evaluation is necessary, since greater attention to those aspects can prompt care that avoids patient harm. The aim of the study was to investigate good nursing care practices for patient safety in intensive care units (ICUs). Methods This was a longitudinal, prospective study seeking correlation between variables by means of repeated observations of the same items over a period of time, based on the extent of subject exposure during events and segments.(16) The study was performed in a general university hospital northwest of São Paulo, with 800 beds. Data were collected in three ICUs: (1) cardiology, (2) neurology, and (3) general. These units were divided into surgical and clinical ICUs. The Barbosa TP, Oliveira GA, Lopes MN, Poletti NA, Beccaria LM surgical ICU had ten beds for patients for delivery of intensive postoperative care after major surgery or due to surgical complications. The clinical ICU also had ten beds for intensive care delivered to patients admitted with diagnoses from all specialties. The sample consisted of 450 observations, 50 assessments performed in each work period. Patients not allowed to perform the proposed actions during assessment were excluded. A checklist was used as an instrument based on quality of care evaluation through bedside checking of good care practices, validated and completed by the researcher three times a week on alternate periods (morning/afternoon/evening) by watching the bedside nursing actions related to patient care, considering the quality indicators. The instrument consisted of three items: hygiene and comfort; identification/prevention of falls, and control/prevention of hospital infection, subdivided into 19 sub-items: tidy bed, position changing, presence of egg crate mattress, patient sitting in armchair, side rails elevated and locked, clean limb restraints without joint circulation restriction, head of the bed elevated above 30°, ventilator circuit identified with date of exchange, ambu circuit protected with plastic bag, date recorded on central catheter dressing and/ or peripheral venous access, IV sets identified with dates, infusion pumps identified with medication names, three-way taps protected with “luer-cone”, urinary catheter properly secured on the thigh, identified bed, identification bracelet on the left arm, ventilator circuit without presence of condensate, urine collection bag below the bladder level, and individual bottle to discard urine. The results were analyzed by G test of independence with Williams correction, which has the same characteristics of x2. Excel® software was used to correlate data by means of clusters in different subgroups through percentages and statistical calculations. The study abided by the national and international standards of research ethics involving human beings. Results In Intensive Care Unit 1: comparing the work shifts regarding hygiene and comfort, the item with the highest disagreement was “position changing”.. During morning and evening periods, 32 (64%) were correct, whereas in the afternoon, only 26 (52%) were correct. Regarding identification, the item that most differed from one shift to another was “infusion pumps”. In the morning period, 49 (98%) were identified and only one (2%) was not. In the afternoon, 47 (94%) were identified and three (6%) were not. In the evening, 39 (78%) were identified and 11 (22%) were not. Concerning control of hospital infection, as for the item “identified ventilator circuit”, 31 (62%) were correct in the morning, 42 (84%) in the afternoon, and 46 (92%) in the evening. Regarding the date of circuit exchange, there was also a significant difference, because in the morning 42 (84%) were identified, 48 (96%) in the afternoon and 37 (74%) in the evening. In Intensive Care Unit 2: regarding hygiene and comfort, the item with the highest disagreement comparing work shifts was “position changing”. In the morning, 19 (38%) had correct position change, 17 (34%) in the afternoon, and 15 (30%) in the evening. Concerning identification, the item “infusion pumps” proved to be different. In the morning, 32 (64%) patients had their pumps identified, 41 (82%) in the afternoon, and 35 (71%) in the evening. With regard to control of hospital infection, the item “correct fixation of indwelling catheters” had different results when shifts were compared. In the morning, 41 (82%) catheters were correctly fixed, 40 in the afternoon (80%), and 30 (60%) in the evening. In Intensive Care Unit 3: in relation to hygiene and comfort, “position changing” was also the item that most differed among work shifts. In the morning, 49 (98%) were correct, 41 in the afternoon (82%), and 32 (64%) in the evening. With reference to identification, the item “ventilator circuit” was discrepant. In the morning, 47 (94%) were identified, 30 in the afternoon (60%) and 22 (44%) in the evening. As for control of hospital infection, “correct fixation of indwelling catheters” was the item with the highest discrepancy comparing shifts. In the morning, 41(82%) catheters were correctly fixed, Acta Paul Enferm. 2014; 27(3):243-8. 245 Care practices for patient safety in an intensive care unit Table 1. Items observed in patients hospitalized in Intensive Care Units 1, 2 and 3 Variables ICU 1 ICU 2 Yes(%) No(%) Yes(%) 137(91.3) 13(8.6) 90(60) 60(40) Egg crate mattress 139(92.6) Patient sitting safely 139(92.6) ICU 3 No(%) Yes(%) No(%) 147(98) 3(2) 130(86.6) 20(13.4) 51(34) 99(66) 122(81.3) 28(18.7) 11(7.3) 145(96.6) 5(3.3) 142(94.6) 8(5.4) 11(7.4) 148(98.6) 2(1.4) 138(92) 12(8) Hygiene and comfort Tidy bed Position change Identification/fall prevention Side rails elevated 142(94.6) 8(5.4) 143(95.3) 7(4.7) 139(92.6) 11(7.4) Clean limb restraints 136(90.6) 14(9.4) 113(75.3) 37(24.7) 90(60) 60(40) Identified bed 144(96) 6(4) 148(98.6) 2(1.4) 145(96.6) 5(3.4) Identification bracelet 141(94) 9(6) 124(82.6) 26(17.4) 138(92) 12(8) Identified infusion pumps 135(90) 15(10) 108(72) 42(28) 141(94) 9(6) 10(6.7) Control of hospital infection Head of the bed elevated 141(94) 9(6) 139(92.6) 11(7.4) 140(93.3) Identified ventilator circuit 119(79.3) 31(20.4) 76(50.6) 74(49.4) 99(66) 51(44) 120(80) 30(20) 128(85.3) 22(14.7) 101(67.3) 49(32.7) Date of central catheter exchange 127(84.6) 23(15.4) 140(93.3) 10(6.7) 130(86.6) 20(13.4) Date of IV set exchange 127(84.6) 23(15.4) 146(97.3) 4(2.7) 136(90.6) 14(9.4) Protected 3-way taps 142(94.6) 8(5.4) 144(96) 6(4) 143(95.3) 7(4.7) 141(94) 9(6) 111(74) 39(26) 125(83.3) 25(16.7) Protected ambu Indwelling catheter correctly fixed Ventilator circuit without condensate 141(94) 9(6) 139(92.6) 11(7.4) 123(82) 27(18) Urine collection bag below the bladder level 149(99.3) 1(0.7) 149(99.3) 1(0.7) 147(98) 3(2) Individual bottle to discard urine 150(100) -(-) 150(100) -(-) 150(100) -(-) Considering the percentage of comparison for 50 patients in each item observed and each shift, with n=50 (100%), according to test G of independence with Williams correlation 40 (80%) in the afternoon, and 30 (60%) in the evening. Regarding protected ambus, 42 (84%) were protected in the morning, 30 (60%) in the afternoon, and 29 (58%) in the evening. Concerning hygiene and comfort, the item “position change” was the most different among shifts. In ICU 2, only 51 (34%) had position change correctly performed, whereas in ICU 3, there were 122 (81.3%). As for identification, the item “clean restraints” had the highest difference. In ICU 1, 136 (90.6%) were clean, and in ICU 3, only 90 (60%). Regarding control of hospital infection, the item “identified ventilator circuit” was the most discrepant, especially between ICUs 1 and 2. In ICU 1, 119 (79.3%) were identified, and in ICU 2, 76 (70.6%). Most items observed were correct, which depicts good results; as for hygiene and comfort, the item “presence of egg crate mattress” was 139 (92.6%) in ICU 1, 145 (96.6%) in ICU 2, and 142 (94.6%) in the ICU 3. Regarding identification and fall prevention, the item “patient sitting in armchair safely” was correct in 139 (92.6%) cases in ICUs 1 and 3, and 246 Acta Paul Enferm. 2014; 27(3):243-8. in 148 (98.6%) cases in ICU 2.. In the control of hospital infection, the item “head of the bed elevated” stood out as a good practice in all ICUs, because in ICU 1, 141 (94%) were correct, 139 (92.6%) in ICU 2 and 140 (93.3%) in ICU 3, demonstrating attention of the nursing team to pneumonia prevention (Table 1). Discussion Comparing the way to work in three shifts in the ICUs regarding hygiene and comfort, there was significant difference in the item “position change”, with relevant significance (p<0.01). This care practice is important for the patient, because it minimizes complications mainly associated with mechanical ventilation and skin integrity, therefore it cannot be overlooked. A Brazilian study found that 40% of the professionals involved in care believed that pressure ulcers occurred due to patients’ hemodynamic instability and complexity, 27% believed they occurred due to staff shortage, which directly affected Barbosa TP, Oliveira GA, Lopes MN, Poletti NA, Beccaria LM changing of position, and 20% believed they occurred due to incorrect care delivery by the nursing team.(17) Those reasons may be involved with the findings of this study, since position change was the care practice with the lowest rates of delivery in all ICUs. The items “tidy bed” and “presence of egg crate mattress” to prevent pressure ulcers were present in the three units for approximately 90% of patients. This care practice is part of pressure ulcer prevention, which has implications for patients’ prognosis and outcome and impact on hospitalization costs, which corroborates a study that found an increase in the length of hospital stay by approximately 6% among patients with pressure ulcers.(18,19) Regarding patient identification, medications used, and fall prevention, the item “clean, dry limb restraint without arm and leg circulation restriction” obtained a relatively high level of significance when the ICUs were compared (p<0.01). Studies show that nurses, as members of the multidisciplinary team and leaders of the nursing team in the ICU, should develop safe and effective ways to provide care. Thereby, systematic forms contribute to recognition of the importance of nursing actions at any level of healthcare.(20) Most (95%) identifications of patient rooms were correct. Concerning the use of the identification bracelet with name, hospital number, mother’s name and date of admission, the rate was 89%. With regard to the control of hospital infection, of the ten items observed, there was disagreement between units in the identification of ventilator circuit exchange, which was 79%, 51% and 66% in ICUs 1, 2 and 3, respectively, exposing the need for greater emphasis on this nursing care activity. Not exchanging the circuit periodically in patients with tracheal tubes significantly increases ventilator-associated pneumonia, and the incidence of respiratory infections by 40%.(21) In general, it was found that good practices were delivered, with an index above 80% for 15 items, with the best results obtained in ICU 1. Irregularities for the 19 items and for the three shifts were observed. However, a larger number was evidenced in the evening, which may be related to the stressful environment itself and sleep changes presented by professionals who work at night, reflecting on care.(22) Ensuring the safety of critically ill patients has been a major challenge for professionals working in the intensive care unit because patients undergo many procedures each day, and in some of these activities, errors may occur with the potential to cause harm.(23) As a consequence, hospitals need to incorporate a policy of risk management with focus on education, establishing preventive barriers at all stages of strategic processes, and identify opportunities to improve care.(22) This study demonstrated that the only care performed 100% was the use of an individual bottle to discard urine. The items performed 90% or more in the three units were: egg crate mattress, patient sitting, side rails elevated, bed identification, head of the bed elevated above 30°, three-way taps protected with “luer cone”, and urine collection bag below the bladder level. Therefore, nurses should take into account the risks when planning care, ensuring and supervising the team, particularly in relation to care, for the improvement of assistance, minimizing of errors and indiscretions.(24) Conclusion Good nursing care practices related to patient safety were delivered in the three units. In an isolated view, care delivery was different in the shifts. Altogether, significant differences were found between ICUs. However, position changing, limb restraints and identification of the mechanical ventilator circuit had the same profile among units, with lower rates of performance. Collaborations Barbosa TP contributed to the project design, research execution and article writing. Oliveira GAA contributed to data collection. Lopes MNA contribActa Paul Enferm. 2014; 27(3):243-8. 247 Care practices for patient safety in an intensive care unit 12. Silva BM, Lima FR, Farias SF, Campos AC. Jornada de trabalho: fator que interfere na qualidade da assistência de enfermagem. Texto & Contexto Enferm. 2008;15(3):442-8. References 14. Beccaria LM, Pereira RA, Contrin LM, Lobo SM, Trajano DHL. Eventos adversos na assistência de enfermagem em unidade de terapia intensiva. Rev Bras Ter Intensiva. 2009;21(3):276-82. 1. Pessalacia JD, Silva LM, Jesus LF, Silveira RC, Otoni A. Atuação da equipe de enfermagem em UTI pediátrica: um enfoque na humanização. Rev Enferm Cent O Min. 2012;2(3):410-8. 15.Machado AF, Pedreira MLG, Chaud MN. Adverse events related to the use of peripheral intravenous catheters in children according to dressing regimens. Rev Latinoam Enferm. 2008;16(3):362-7. 2. Vila VS, Rossi LA. O significado cultural do cuidado humanizado em unidade de terapia intensiva: “muito falado pouco vivido”. Rev Latinoam Enferm. 2009;10(2):137-44. 16.Morton PG, Fontaine DK, Hudak CM, Gallo MB. Cuidados críticos de enfermagem: uma abordagem holística. 8a ed. Rio de Janeiro: Guanabara Koogan; 2007. 3. Alves EF. O Cuidador de Enfermagem e o cuidar em uma unidade de terapia intensiva. Rev Cient Ciênc Biol Saúde. 2013;15(2):115-22. 17. Castellões TM, Silva LD. Ações de enfermagem para a prevenção de extubação acidental. Rev Bras Enferm. 2009;62(4):540-5. 4. Padilha KG, Kitahara PH, Gonçalves CC, Sanches AL. Ocorrências iatrogênicas com medicação em unidade de terapia intensiva: condutas adotadas e sentimentos expressos pelos enfermeiros. Rev Escola Enferm USP. 2010;36(1):50-7. 18. Barbosa TP, Beccaria LM, Pereira RA. Avaliação da experiência de dor pós-operatória em pacientes de unidade de terapia intensiva. Rev Bras Ter Intensiva. 2011;23(4):223-7. 5. 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Diagnósticos de enfermagem de pacientes pós-cateterismo cardíaco- contribuição de Orem. Rev Bras Enferm. 2006;59(3):285-90. 21. Beraldo CC, Andrade D. Higiene bucal com clorexidena na prevenção de pneumonia associada à ventilação mecânica. J Bras Pneumol. 2008;34(9):707-14. 22. Costa ES, Morita I, Martinez MA. Percepção dos efeitos do trabalho em turnos sobre a saúde e a vida social em funcionários da enfermagem em um hospital universitário do Estado de São Paulo. Cad Saúde Pública. 2009;16(2):553-5. 23. Brasil. Ministério da Saúde. Portaria nº 529, de 1º de abril de 2013. Institui o Programa Nacional de Segurança do Paciente (PNSP). Diário Oficial da República Federativa do Brasil; 2011 [citado 2013 Set 11]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2013/ prt0529_01_04_2013.html. 24.Compromisso com a qualidade hospitalar (CQH) [Internet]. Manual de indicadores de enfermagem NAGEH. 2a ed. São Paulo: APM/ CREMESP; 2012. [citado 2013 Set 11]. Disponível em: http://www. cqh.org.br/portal/pag/doc.php?p_ndoc=125. Original Article Analysis of blood pressure records at post-anesthesia recovery room Análise dos registros da pressão arterial na sala de recuperação pós-anestésica Aline Aparecida Souza Cecílio1 Aparecida de Cássia Giani Peniche2 Débora Cristina Silva Popov2 Keywords Arterial pressure; Operating room nursing; Perioperative nursing; Anesthesia recovery period; Posthanesthesia nursing Descritores Pressão arterial; Enfermagem de centro cirúrgico; Enfermagem perioperatória; Período de recuperação da anestesia; Enfermagem em pós-anestésico Abstract Objective: To analyze the blood pressure records and their accuracy in the score of the circulation item at the post-anesthesia recovery room. Methods: Cross-sectional study of the postoperative records from 23 histories of patients admitted to the post-anesthesia recovery room after small and medium-sized surgeries. The Aldrete-Kroulik index was used. Statistical analysis was applied in numerical and percentage terms. Results: Upon the patients’ admission, 48% of the records for the circulation item were not accurate. At the patients’ discharge, 39% were assessed imprecisely. Conclusion: In some cases, the quality of the records and the accuracy of the Aldrete-Kroulik index score for the circulation item were not observed, compromising patient safety. Resumo Submitted February 7, 2014 Accepted May 26, 2014 Objetivo: Analisar os registros da pressão arterial e sua acurácia na pontuação do item circulação na sala de recuperação pós-anestésica. Métodos: Estudo transversal que incluiu os registros pós-operatórios de 23 prontuários de pacientes admitidos na sala de recuperação pós-anestésica após cirurgias de pequeno e médio porte. Foi utilizado o índice de Aldrete e Kroulik. Foi realizada análise estatística numérica e percentual. Resultados: Na admissão dos pacientes, 48% dos registros do item circulação não mostraram acurácia. Na avaliação da alta do paciente, 39% deles foram avaliados de forma imprecisa. Conclusão: Em alguns casos, não foram observadas a qualidade do registro e a acurácia da pontuação do item circulação do índice de Aldrete e Kroulik, comprometendo a segurança do paciente. Corresponding author Débora Cristina Silva Popov Dr. Enéas de Carvalho Aguiar Avenue, 419, São Paulo, SP, Brazil. Zip Code: 05403-000 [email protected] DOI http://dx.doi.org/10.1590/19820194201400042 Universidade de Santo Amaro, São Paulo, SP, Brazil. Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, Brazil. Conflicts of interest: no conflicts of interest to declare. 1 2 Acta Paul Enferm. 2014; 27(3):249-54. 249 Analysis of blood pressure records at post-anesthesia recovery room Introduction The first 24 hours of the postoperative period, called immediate postoperative period, demand attention from the multiprofessional and nursing teams, which follow the patients from their entry in the post-anesthesia recovery room until their discharge from this unit.(1) To guarantee patient safety in that period, the nurses need to perform some care actions until the vital signs and protective reflexes have been stabilized, guaranteeing the patients’ comprehensive assessment, according to the surgical procedure, anesthetic agents and individual risks. They also need to heed any complications that may occur in the immediate postoperative period, such as respiratory, cardiovascular and renal complications, among others.(2) In 1970, the Aldrete-Kroulik index was developed, submitted to a revision and update in 1995. This index is used to systemize the observation of the patients’ physiological conditions and discharge from the post-anesthesia recovery room.(1) The Aldrete-Kroulik index assesses the motor, respiratory, circulatory and neurologic activities, with a score ranging from zero to two points for each parameters, in which zero indicates the most severe condition, 1 the intermediary condition and 2 that the functions have already been established. According to the Aldrete-Kroulik index, the patient receives discharge from the post-anesthesia recovery room and is transferred to the unit of origin when reaching the total score between 8 and 10 points.(3) It should be highlighted that the index is one way to assess the patient, which does not discard the need for complementary assessments, like pain, temperature, nausea and vomiting for example, among others.(2,4) This scenario entails insecurity regarding the patient’s forwarding to the unit of destination. The blood pressure assessment may be compromised and the patient may be subject to complications or discomfort related to hypo or hypertension. The difficulty in the application of the Aldrete-Kroulik index is mainly related to the assess- 250 Acta Paul Enferm. 2014; 27(3):249-54. ment of the circulatory system, as the identification of the preoperative blood pressure is needed to obtain the score. Thus, the patient receives score 2 on the circulation item if the blood pressure varies within 20% of the pre-anesthesia level; 1 if the pressure varies between 20 and 49% of the pre-anesthesia value; and zero if the variation exceeds 50% of the pre-anesthesia value. The blood pressure needs to be calculated appropriately and compared with the preoperative levels. It is fundamental for the nursing team to know this information, as the correct application of the Aldrete-Kroulik index grants safety to transfer the patient to the unit of destination. The mistaken completion of this assessment parameter can expose the patient to risk situations and lead to the worsening of his general status.(3) This study aimed to analyze the blood pressure records and their accuracy in scoring the “circulation” item, according to the Aldrete-Kroulik index, at the post-anesthesia recovery room. Methods This cross-sectional study was undertaken at a hospital in the city of São Paulo, State of São Paulo, in the Southeast of Brazil, considering 23 histories of patients submitted to small and medium surgeries between May and July 2013. Patients over 12 years of age who spent more than 45 minutes at the recovery room were included. The sample corresponded to 41% of the mean number of patients admitted to the post-anesthesia recovery room during that period. The mean number of surgeries at the service was 51 surgeries/month, and the mean number of admissions to the post-anesthesia recovery room 19 patients/month. The data collection instrument was a questionnaire that verified the patients’ demographic characteristics (sex, previous disease and age, surgical procedure data), surgical specialty, type of anesthesia, classification of anesthetic risk according to the American Society of Anesthesiologists (ASA) and perioperative problems. Cecílio AA, Peniche AC, Popov DC Healthy patients without previous diseases are classified as ASA I; patients with mild systemic disease as ASA II; patients with severe systemic disease as ASA III; patients with intense systemic disease that represents a constant death risk as ASA IV; dying patients as ASA V; and brain-dead patients who are organ donors as ASA VI.(2) As perceived, the nursing professional at the post-anesthesia recovery room has not properly assessed the parameters of the Aldrete-Kroulik index, mainly regarding the assessment of the circulation, which demands a numerical calculation that is rarely used. The following data were collected from the “circulation” item of the Aldrete-Kroulik index: preoperative blood pressure; blood pressure upon admission to and discharge from the post-anesthesia recovery room, percentage of variations between pre- and post-operative pressure levels and score registered in the patient file. The data were analyzed to verify the accuracy of the score as well as the register of the Aldrete-Kroulik index. Hence, the percentage variation between the preoperative systolic and diastolic blood pressure was calculated upon admission and the postoperative systolic and diastolic blood pressure upon the patients’ discharge from the post-anesthesia recovery room. After identifying these variables, the Aldrete-Kroulik index was again applied and the precision of the item scored was analyzed. The results were analyzed and presented in tables, using numerical and percentage statistics. The study development complied with the Brazilian and international ethical standards for research involving human beings. tem, followed by endocrine diseases; 9 (39%) patients denied the existence of diseases. Four presented associated cardiovascular and endocrine diseases. The patients’ mean age was 41.7 years, with seven patients (31%) over 60 years of age, followed by the adult age range between 30 and 40 years (22%). Concerning the surgical specialties, 12 (52%) were related to otorhinolaryngology, seven (31%) to general surgery, two (9%) to orthopedics, one (4%) to ophthalmology and one (4%) to dentistry. As regards the anesthetic procedure, 13 (57%) were submitted to balanced general anesthesia, seven (30%) to spinal and epidural anesthesia + sedation and three (13%) to block + sedation. What the ASA estimate and risk are concerned, ten patients (43%) were classified as ASA I, five (22%) as ASA II and three (13%) as ASA III. In five patients’ files (22%), two classifications were found. In tables 1 and 2, the variations between the blood pressure records upon the patient’s admission and discharge from the post-anesthesia recovery room are displayed. In 4% of the files analyzed, no records were found of the blood pressure upon the patient’s admission to the post-anesthesia recovery room. Results Table 2. Variations in blood pressure and records upon discharge According to the demographic characteristics indicated in the 23 files selected for this study, 16 (70%) patients were female. As regards previous diseases, 14 (61%) patients presented a disease, most of which related to the cardiovascular sys- Table 1. Variations in blood pressure and records upon admission Blood pressure alteration (%) n(%) Correct records >20 11(48) 11 20-49 8(35) 0 >50 3(13) 0 No records 1(4) - 23(100) - Total Blood pressure alteration (%) n(%) Correct records >20 13(57) 13 20-49 8(35) 0 >50 1(4) 0 No records 1(4) - 23(100) - Total Acta Paul Enferm. 2014; 27(3):249-54. 251 Analysis of blood pressure records at post-anesthesia recovery room Discussion The study was undertaken at a hospital that mostly performs outpatient surgeries, that is, the patient is admitted for the surgery and discharged the same day, after stabilizing from the surgery and anesthesia. The research limits are related to the cross-sectional design, which does not permit the establishment of cause and effect relations. The study results showed that most (70%) of the patients admitted to the post-anesthesia recovery room were female. In a study of 260 histories of patients submitted to small surgeries, women were also predominant, corresponding to 54.5% of the study sample.(5) The predominance of the female sex may be related to the type of care delivered at the study hospital, but this fact did not interfere in the proposed results and objectives. Studies show that the female population tends to visit health services more frequently and are forwarded more frequently for small and medium surgeries than men, mainly elective surgeries, in which the patient seeks the service due to some specific problem.(5) Another result found was the number of patients with previous diseases. In this study, cardiovascular diseases were predominant (61%), followed by endocrine diseases. Systemic arterial hypertension was the most prevalent previous disease. In Brazil, today, hypertension is considered one of the main health problems in the adult and elderly populations, raising healthcare costs and entailing risks for the accomplishment of surgical procedures.(6) The instability of the cardiovascular system is frequent after surgeries. Therefore, the nursing team needs to heed possible complications in that period as, if the manifestations are not detected and treated early, the patient may evolve with a clinical problem, extending the length of recovery and increasing the chances of postoperative and anesthetic complications. Systemic arterial hypertension at the post-anesthesia recovery room may be related to pain, bladder distension and neuromuscular agitation, among other reasons. In patients with a history 252 Acta Paul Enferm. 2014; 27(3):249-54. of previous cardiac problems, attention is needed due to complication risks.(2) The nurses’ careful assessment of vital signs and the patient during that period should be done and documented, guaranteeing patient safety. Another common previous disease among those classified as endocrine in this study is diabetes mellitus, mainly type 2. The association between systemic arterial hypertension and diabetes mellitus is a frequent finding in preoperative assessments.(2,7) The patients’ mean age was 41.7 years. In this study, most patients (53%) were over 30 years of age and 31% over 60 years of age. In a study that aimed to classify the recovery room patients according to the degree of dependence, the patients’ mean age was 51.57 years. In another study, which investigated the patients’ mean complications at the post-anesthesia recovery room, found that most patients were over 30 years of age (75.67%).(8-10) At many services, care at the post-anesthesia recovery room has been focused on young adult patients. In this study, we found the prevalence of elderly people, probably due to the increase of this age range in the Brazilian population, as well as the greater possibility of specialized healthcare and treatment resources, like surgeries of different dimensions for example. This profile arouses reflections about the need to reconsider the care and the dependence level, mainly in the immediate postoperative period.(11) The surgical specialties found are related to the characteristics of the study hospital, which is an outpatient care hospital. That explains why small and medium surgeries have been performed, due to the care in specialty areas like otorhinolaryngology and ophthalmology. The most identified anesthesia type was general balanced anesthesia (57%), in which the drugs are administered through the intravenous and inhalation route, followed by spinal and epidural anesthesia (30%) and blocks with sedation (13%). Other studies also found general anesthesia as the most frequent, like in a study involving 65 patients for example, which was Cecílio AA, Peniche AC, Popov DC aimed at identifying the most prevalent nursing diagnoses at the post-anesthesia recovery room. General anesthesia was registered in 86.1% of the cases, followed by spinal and epidural anesthesia in 7.7%.(12) Lima et al. found that general anesthesia was the most prevalent in 76.1% of the anesthetic procedures performed.(9) The use of general anesthesia comes with a specific patient profile with well-defined needs for the post-anesthesia recovery room. It is important for the nurses to recognize the most frequent type of anesthesia as, thus, they can know the changes related to the drugs involved in the different procedures faster and more easily. In general anesthesia, changes like a reduced level of awareness, delay to wake up, nausea, vomiting, agitation, hypothermia, among others, are common. According to the ASA classification, most patients in this study is classified as ASA I, although there were ASA II and III patients as well. Studies include this classification as an important indicator of the patient’s level of dependence on nursing care and the length of their stay at the post-anesthesia recovery room. In the analysis of the patients’ level of dependence on nursing care at the post-anesthesia recovery room, a study found that, as the length of the patient’s stay at the recovery room increases, the higher his dependence level on nursing care will be and the higher the ASA classification. This fact may indicate the need to adapt the available resources and to train the nurses.(9) The ASA classification is an important indicator of the patient’s level of severity and of the risk possibilities during the anesthesia-surgery procedure. Therefore, nurses should be familiar with this patient assessment support instrument, especially when considering that patients superior to ASA III should be submitted to anesthetic procedures at hospital services with hospitalization. The results indicated accurate records (11 patients; 48%) upon the patient’s admission, when the blood pressure differed by up to 20% from the preoperative level. When observing the cases of changes between 20 and 50% and superior to 50% of the blood pressure level, however, we found records that did not correspond to the patient’s actual situation. In a study that identified the main nursing diagnoses at the recovery room, it was shown that the risk of disequilibrium in the fluid volume was found in 100% of the patients studied, that is, any patient at the post-anesthesia recovery room is at risk of circulatory instability, which may be related to a fluid deficit (hemorrhage), dehydration, ineffective volemic replacement, arrhythmias, besides hyper or hypotension associated with drug use, like the drugs used in spinal and epidural anesthesia for example.(12) The incidence of acute pain should also be considered, responsible for blood pressure increases, especially in the systolic blood pressure. In a study about complications and nursing interventions at the post-anesthesia recovery room, pain appeared as a common complication (54% of the patients studied). The same study found arterial hypertension in 4.5% of the patients and hypotension in 3.2% of the cases, besides 6% of patients with hemorrhages.(2,12) In another study, it was evidenced that about 64% of the patients submitted to anesthesia present episodes of systolic blood pressure <90mmHg and that more than 93% of them develop at least one episode of systolic blood pressure and mean blood pressure below 20% of the baseline value.(13) The results for the patients’ discharge are similar to the admission results. The records in the files of all patients are accurate when the blood pressure change corresponds to up to 20% (13 patients; 57%). In the other records, however, once again the professional’s records were not exact (9 patients; 39%). In addition, the absence of records for the “circulation” item was noteworthy in 4% of the histories for the patients in this study. The assessment of the results found in this study was not intended to demonstrate the reasons for inaccurate Aldrete-Kroulik index registers. Therefore, further research is suggested to identify these reasons and consider educative measures directed at the professionals working at the post-anesthesia recovery room. Acta Paul Enferm. 2014; 27(3):249-54. 253 Analysis of blood pressure records at post-anesthesia recovery room The Aldrete-Kroulik index records are used as a parameter for discharging the patients from the recovery room, but are not used in isolation. Other parameters like pain, nausea and vomiting, respiratory pattern, among others, are also considered. The register of the item “circulation” in particular involves calculations and, as perceived, accuracy difficulties were observed, which could be related to this calculation and, consequently, to its appropriate interpretation. Another factor to be considered is the characteristic of the post-anesthesia recovery unit, which is marked by high turnover, which can cause difficulties for records and their appropriateness to the patient’s actual situation.(9) This can compromise the quality of care delivery at the post-anesthesia recovery room, ranging from appropriate records to patient safety, due to the lack of records and the possibility of enhanced risks due to the discontinuity of the care. Conclusion In some cases, high-quality records and accurate scores of the “circulation” item in the Aldrete-Kroulik index were not observed, compromising the patient safety. Collaborations Cecílio AAS contributed to the project conception, analysis and interpretation of the data and writing of the article. Peniche ACG cooperated with the final approval of the version for publication a. Popov DCS cooperated with the project conception, writing of the article and relevant critical review of the intellectual content. 254 Acta Paul Enferm. 2014; 27(3):249-54. References 1. Barrreto RA, Barros AP. Conhecimento e promoção de assistência humanizada no centro cirúrgico. Rev SOBECC. 2009;14(1):42-50. 2. Popov DC, Peniche AC. [Nurse interventions and the complications in the post-anesthesia recovery room]. Rev Esc Enferm USP. 2009; 43(4): 953-61. Portuguese. 3. Reis CT, Martins M, Laguardia J. [Patient safety as a dimension of the quality of health care – a look at the literature]. Ciênc Saúde Coletiva. 2013; 18(7): 2029-36. Portuguese. 4. Castro FS, Peniche AC, Mendoza IY, Couto AT. Temperatura corporal, índice Aldrete e Kroulik e alta do paciente da Unidade de Recuperação Pós-Anestésica. Rev Esc Enferm USP. 2012;46(4):872-6. 5. Secoli SR, Moraes VC, Peniche AC, Vattimo MF, Duarte YA, Mendonza IYQ. [Post operative pain: analgesic combinations and adverse effects]. Rev Esc Enferm USP. 2009; 43(Esp 2):1244-9. Portuguese. 6.Sociedade Brasileira de Cardiologia/Sociedade Brasileira de Hipetensão/Sociedade brasileira de Nefrologia. IV Diretrizes brasileiras de Hipertensão. Arq Bras Cardiol. 2010;95(Supl 1):1-51. 7. Sociedade Brasileira de Diabetes (SBD) Diretrizes da SBV 2009 [Internet]. Disponível em: http://www.diabetes.org.br/publicacoes/ diretrizes-e-posicionamentos. 8. Moro ET, Godoy RC, Goulart AP, Muniz L, Modolo NS. [Main concerns of patients regarding the most common complications in the post-anesthetic care unit]. Rev Bras Anestesiol. 2009; 59(6);716-24. Portuguese. 9. Lima LB, Borges D, Costa S, Rabelo ER. Classificação de pacientes segundo o grau de dependência dos cuidados de enfermagem e a gravidade em unidade de recuperação pós-anestésica. Rev Latinoam Enferm. 2010;18(5): 881-7. 10.Santos MR, Silva SHC, Poveda VB. [Hypothermia in patients undergoing cesarean section]. Rev SOBEC. 2011;16(4):26-30. Portuguese. 11.Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional por amostra de domicílios - PNAD 2004 [Internet]. Disponível em http://www.ibge.gov.br/mtexto/pnadcoment1.htm. 12.Souza TM, Carvalho R, Paldino CM. [Nursing diagnoses, prognostics and interventions in the post-anesthesia care unit] Rev Sobec. 2012;17(4):33-47. Portuguese. 13. Bijker JB, van Klei WA, Vergouwe Y, Eleveld DJ, van Wolfswinkel L, Moons KG, et al. Intraoperative hypotension and 1-year mortality after noncardiac surgery. Anesthesiology. 2009;111(6):1217-26. Original Article Difficulties faced by parents of children with gastroesophageal reflux disease Dificuldades enfrentadas pelos pais de crianças com doença do refluxo gastroesofágico Jacqueline Andréia Bernardes Leão Cordeiro1 Sacha Martins Gualberto1 Virginia Visconde Brasil1 Grazielle Borges de Oliveira2 Antonio Márcio Teodoro Cordeiro Silva2 Keywords Child; Gastroesophageal reflux; Family; Nursing care; Pediatric nursing Descritores Criança; Refluxo gastroesofágico; Família; Cuidados de enfermagem; Enfermagem pediátrica Submitted February 17, 2014 Accepted May 26, 2014 Abstract Objective: Identifying the difficulties faced by parents of children with gastroesophageal reflux disease. Methods: Qualitative study carried out with 16 parents of children with gastroesophageal reflux disease. A guiding question was used and the interviews were recorded and transcribed. Results: Eight categories related to the difficulties faced by parents emerged, as follows: frequent vomiting, pneumonia, cost of treatment, impaired social interaction, weight loss and disturbed sleep pattern, causing difficulty in adhering to treatment with insufficient guidance. Conclusion: The difficulties faced by parents of children with gastroesophageal reflux were represented by categories that can serve as indicators for the quality of provided care. Resumo Objetivo: Identificar as dificuldades enfrentadas pelos pais de crianças com doença do refluxo gastroesofágico. Métodos: Pesquisa qualitativa realizada com 16 familiares de crianças com doença do refluxo gastroesofágico. Foi utilizada uma questão norteadora, as entrevistas foram gravadas e transcritas. Utilizou-se a técnica de análise de conteúdo. Resultados: Emergiram oito categorias relacionadas às dificuldades enfrentadas pelos pais: vômitos frequentes, pneumonia, custo com tratamento, convívio social prejudicado, perda de peso, padrão de sono prejudicado, gerando dificuldade na adesão ao tratamento com orientações insuficientes. Conclusão: As dificuldades enfrentadas pelos pais de crianças com refluxo gastroesofágico foram representadas por categorias que podem servir de indicadores para a qualidade do cuidado prestado. Corresponding author Jacqueline Andréia Bernardes Leão Cordeiro 227 street, 68 block, unnumbered, Goiânia, GO, Brazil. Zip Code: 74605-080 [email protected] DOI http://dx.doi.org/10.1590/19820194201400043 Universidade Federal de Goiás, Goiânia, GO, Brazil. Pontifícia Universidade Católica de Goiás, Goiânia, GO, Brazil. Conflicts of interest: no conflicts of interest to declare. 1 2 Acta Paul Enferm. 2014; 27(3):255-9. 255 Difficulties faced by parents of children with gastroesophageal reflux disease Introduction The gastroesophageal reflux (GER) is characterized by the involuntary passage of gastric contents into the esophagus and may occur several times during the day in healthy children and adults, being classified as physiological or pathological. It reaches 7-8% of children and is present in about 50% of children in the first four months of life.(1) The reflux is characterized as physiological when presented in the first months of life. The postprandial regurgitation arises between birth and the first six months of life, often with spontaneous resolution until the first year of the child.(2-4) In this context, conservative strategies that do not require medication therapy are indicated, since they have several benefits, low cost and no side effects.(3,5-7) In addition to vomiting and regurgitation, other signs and symptoms are present in the gastroesophageal reflux disease, impairing the clinical status of patients. This clinical impairment may be primary, with some dysfunction in the esophageal-gastric junction, or secondary, when it results from food allergy or intestinal obstruction.(2,8,9) The difficulty of professionals is noticeable in the daily practice of care to children with gastroesophageal reflux, in the management of these patients. Some measures are important to minimize or avoid the onset of reflux.(2,3,10) In this aspect, nurses are indispensable caregivers, and the adherence of parents to treatment is critical in order to reach a successful outcome of the nursing guidelines. The relevance of the study for nursing is linked to ensuring quality of treatment and effectiveness in child care. It is believed that nurses can make a difference because of the specificity of the profession, when leaving the reductionist approach focused on the illness for the biopsychosocial approach, by ensuring relevant guidance and unlimited support to parents or guardians of children with this condition. The objectives of this study were to identify the difficulties faced by parents of children with gastro- 256 Acta Paul Enferm. 2014; 27(3):255-9. esophageal reflux and develop an educational brochure with relevant guidelines to the topic. Methods It is a descriptive study with qualitative analysis, focused on the subjects’ expression of subjectivity. In qualitative research, results are developed in a natural situation with an open and flexible plan and addressing the reality in a complex and contextualized way.(11,12) This research was carried out at a large institution in the city of Goiânia, Goiás, west central region of Brazil. It attends approximately twenty parents of children with gastroesophageal reflux per month. The parents or guardians of children served in the outpatient clinic of Gastroenterology participated in the study. In total, were included 16 parents of children aged between zero and five years who met the following inclusion criteria: age over 18 years and being a companion at the time of consultation. In order to achieve the proposed objectives, the adopted procedure for data collection were interviews based on the following guiding question: What are the difficulties you face when caring for a child with gastroesophageal reflux? For data analysis, the technique of content analysis was used.(13) Parents were interviewed and the statements were filed in a digital recorder, with subsequent full transcript. The development of study followed national and international standards of ethics in research involving human beings. Results Eight categories related to the difficulties faced by parents of children with gastroesophageal reflux were identified: Frequent vomiting, pneumonia, cost of treatment, impaired social interaction, weight loss, impaired sleep pattern, difficulty in treatment adherence and insufficient guidance. Cordeiro JA, Gualberto SM, Brasil VV, Oliveira GB, Silva AM Discussion Limitations of this study are related to qualitative design that allows the identification of the meanings of phenomena and qualitative characteristics that make the object of study, without establishing relations of cause and effect. The categories related to the difficulties faced by parents of children with gastroesophageal reflux were: frequent vomiting, pneumonia, cost of treatment, impaired social interaction, weight loss, impaired sleep patterns, difficulty in treatment adherence and insufficient guidance. The presence of vomiting is closely related to the child’s position, especially in the postprandial period.(9,14) Regarding vomiting, 75% of parents reported difficulty with its management, and in relation to positioning approximately 20% had problems. Although nonspecific, vomiting and regurgitation are the most characteristic symptoms of gastroesophageal reflux.(2,3,15) The high number of children with these episodes in the first two quarters of life may be a result of early weaning and the introduction of complementary feeding, since the offered amount is imposed by the caregiver and not necessarily controlled by the child.(5,14) The small gap between meals, the positioning and handling of the child in the postprandial period may contribute to the presence of gastroesophageal reflux (GER), and in children who are more sensitive to the presence of gastric contents into the esophagus, it can trigger symptoms similar to esophagitis, justifying the suspicion diagnosis of gastroesophageal reflux.(5,9,16) According to testimonies, vomiting and/or regurgitation are present in the lives of these children, causing anxiety in parents. This fact requires further approximation of nurses, in an attempt to minimize this situation with care and the guidance appropriated to the level of understanding of the family. Also in relation to vomiting and regurgitation, pneumonia is the pathology that became common in the lives of these children. All respondents reported that their children had pneumonia at least once during treatment. Gastroesophageal reflux can cause respiratory disease by two mechanisms: vasovagal response and tracheal aspiration of gastric contents.(3,10,17) Tracheal aspiration is considered the main risk factor for the occurrence of recurrent respiratory infections, asthma attacks and worsening of patients with chronic lung disease.(3) The aspiration of gastric contents may occur especially at night, when the child is lying and has persistent cough and difficulty breathing. There should also be a suspect of reflux when the patient is awakened by asthma-like attacks, bronchopneumonic processes or sinusitis without evident cause.(2) Guidance provided by the nurse, such as positioning the child in the elevated left lateral decubitus, not lying down immediately after meals and not eating fatty or greasy foods can bring benefits during treatment and avoid various complications such as pneumonia, sinusitis and frequent hospitalizations, relieving the anguish of the family.(8) The emotional distress of parents of children with GER is often related to financial difficulties. Faced with the impossibility of completely funding the treatment of the disease, the family feel helpless and anxious, since they also need to meet domestic and personal needs, which remain in the background. Many times, the high cost of the prescribed milk, the diet with specific foods, and the costs with medications hamper adherence to treatment.(14) Working in the health area requires the training of professionals, who need technical and scientific expertise, in addition to sensitiveness to the reality of the population they work with. Therefore, the financial difficulties of the families should be taken into account in the set of actions developed to solve the problem. Children with gastroesophageal reflux have some problems related to feeding that reflect in their social lives.(2,3,5,13) In this study, it was possible to observe the difficulties of families due to depriving their children of various foods common to healthy children. Such as occurred with exposure to certain situations in commemorative celebrations, visits to relatives and friends, when children manifested willingness to eat not recActa Paul Enferm. 2014; 27(3):255-9. 257 Difficulties faced by parents of children with gastroesophageal reflux disease ommended foods. This social deprivation negatively impacts on the entire family context because the social isolation of the child, therefore, results in the isolation of parents.(5,18) Regurgitation, vomiting, functional dysphagia, acid or bitter taste in the mouth, postprandial discomfort, nausea and abdominal pain are symptoms that usually affect children with gastroesophageal reflux disease, leading to significant weight loss. (2,3,18,19) Many parents reduce the supply of food in face of the discomfort felt by their children and have difficulty in administering sufficient quantities of food in a timely manner.(5) The resultant digestive symptoms, which often contribute to functional impairment, make children inappetent. Children with gastroesophageal reflux disease may also develop oral hypersensitivity, hindering the acceptance of foods of different consistencies and textures. In this sense, the nurse has an important role with food guidance, such as not offering acid, fatty or forbidden foods like chocolate and soda, as well as maintaining a fractioned and preferably pasty diet.(3,16,20) Other features presented by children with gastroesophageal reflux are irritability, excessive crying, sleep disorders, hiccups, restlessness and refusal to eat. These symptoms are routine reasons for consultations, especially for infants younger than three months. At this age, 50% of infants have gastroesophageal reflux, and therefore the coexistence of these findings itself, does not constitute a causal relationship.(3,5,16) Experiencing gastroesophageal reflux on a daily basis can mean physical and emotional distress of both the child, as the caregiver. The discomfort caused by the symptoms of the disease makes children angry and tearful, requiring extreme dedication and attention of parents to ensure that more severe complications do not occur, such as aspiration followed by respiratory arrest. In this sense, nurses need to be alert to provide adequate information about sleep management and emergency training in case a more serious event occurs.(3,6,21) Although gastroesophageal reflux in children is quite common, this study found there are still great difficulties in full adherence to the treatment and 258 Acta Paul Enferm. 2014; 27(3):255-9. the provided guidance. This is because adherence is subject to many factors such as demographic, social and economic conditions, the nature of the disease, the treatment characteristics, as well as the relationship of the patient with health professionals.(22) Thus, the first step of treatment is the proper parental guidance about what is the gastroesophageal reflux disease, with emphasis on symptoms arising from inadequate diets and possible complications resulting from the non-use of prescribed medications. Guidelines should be adapted to the socioeconomic profile of those involved, extending to all family members, in order to involve them in the commitment to properly caring for the child.(3) The diagnosis of pediatric gastroesophageal reflux disease is made by clinical history and tests (endoscopy, radiological contrast examination of the esophagus, scintigraphy, manometry, 24-hour pH monitoring, therapeutic test). The treatment is clinical, with behavioral and pharmacological measures and, in the case of complications, the surgical endoscopic treatment may be necessary. The nursing care should be family-centered, in close communication between nurses and parents, keeping them informed throughout the therapeutic process about possible complications, and especially the ways to minimize and correct this situation. Conclusion The difficulties faced by parents of children with gastroesophageal reflux disease were represented by the following categories: frequent vomiting, pneumonia, cost of treatment, impaired social interaction, weight loss, impaired sleep patterns, difficulty in treatment adherence and insufficient guidance. Collaborations Oliveira GB and Gualberto SM contributed to the project design, execution of the research and writing of the article. Brasil VV and Silva AMTC collaborated with the relevant critical revision of the intellectual content. Cordeiro JABL contributed to the project design and execution Cordeiro JA, Gualberto SM, Brasil VV, Oliveira GB, Silva AM of research, writing the article and final approval of the version to be published. 11.Reynolds J, Kizito J, Ezumah N, Mangesho P, Allen E, Chandler C. Quality assurance of qualitative research: a review of the discourse. Health Res Policy Syst. 2011;9:43. 12. Miller WR. Qualitative research findings as evidence: utility in nursing practice. Clin Nurse Spec. 2010;24(4):191-3. References 13.Minayo MC. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: Hucitec; 2007. 1. Ratier JC, Pizzichini E, Pizzichini M. Doença do refluxo gastroesofágico e hiperresponsividade das vias aéreas: coexistência além da chance? J Bras Pneumol. 2011;37(5):680-8. 14.Omari T. Gastroesophageal reflux in infants: can a simple left side positioning strategy help this diagnostic and therapeutic conundrum? Minerva Pediatr. 2008;60(2):193-200. 2. Koda YK. Refluxo gastroesofágico em pediatria. São Paulo: Editora de Projetos Médicos; 2007. 15.Federação Brasileira de Gastroenterologia, Sociedade Brasileira de Endoscopia Digestiva, Colégio Brasileiro de Cirurgia Digestiva, Sociedade Brasileira de Pneumologia, Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Doença do refluxo gastroesofágico: tratamento não farmacológico. Rev Assoc Med Bras. 2012;58(1):18-24. 3. Rosen R. Gastroesophageal reflux in infants: more than just a phenomenon. JAMA Pediatr. 2014;168(1):83-9. 4. Farahmand F, Najafi M, Ataee P, Modarresi V, Shahraki T, Rezaei N. Cow’s milk allergy among children with gastroesophageal reflux disease. Gut Liver. 2011;5(3):298-301. 5. Teixeira BC, Norton RC, Pena FJ, Camargos PA, Lasmar LM, Macedo AV. Refluxo gastroesofágico e asma na infância: um estudo de sua relação através de monitoramento do pH esofágico. J Pediatr. 2007;8(6):535-40. 6. Kang SK, Kim JK, Ahn SH, Oh JE, Kim JH, Lim DH, Son BK. Relationship between silent gastroesophageal reflux and food sensitization in infants and young children with recurrent wheezing. J Korean Med Sci. 2010;25(3):425-8. 7. Corvaglia L, Monari C, Martini S, Aceti A, Faldella G. Pharmacological therapy of gastroesophageal reflux in preterm infants. Gastroenterol Res Pract. 2013;2013:714564. 8. Chung EY, Yardley J. Are there risks associated with empiric acid suppression treatment of infants and children suspected of having gastroesophageal reflux disease? Hosp Pediatr. 2013;3(1):16-23. 16. Ferreira CT, Carvalho E, Sdepanian VL, Morais MB, Vieira MC, Silva LR. Gastroesophageal reflux disease: exaggerations, evidence and clinical practice. J Pediatr (Rio J). 2014;90(2):105-18. 17. Erkan ME, Ozkan A, Yilmaz A, Asik M, Gunes C, Yilmaztekin MZ, Dogan AS. The scintigraphic findings of gastroesophageal reflux in children is related to body weight? J Clin Med Res. 2014;6(1):17-20. 18.Hegar B, Satari DH, Sjarif DR, Vandenplas Y. Regurgitation and gastroesophageal reflux disease in six to nine months old indonesian infants. Pediatr Gastroenterol Hepatol Nutr. 2013;16(4):240-7. 19.Falconer J. Gastro-oesophageal reflux and gastrooesophageal reflux disease in infants and children. J Fam Health Care. 2010;20(5):175-7. 20. Acierno SP, Chilcote HC, Edwards TC, Goldin AB. Development of a quality of life instrument for pediatric gastroesophageal reflux disease: qualitative interviews. J Pediatr Gastroenterol Nutr. 2010;50(5):486-92. 9. Baker SS, Roach CM, Leonard MS, Baker RD. Infantile gastroesophageal reflux in a hospital setting. BMC Pediatr. 2008;8:11. 21. Urrego AM, Benítez CA. Caracterización psicológica de las familias de niños con enfermedad por reflujo gastroesofágico. Revista Gastrohnup. 2011;13(1):4-9. 10. Golski CA, Rome ES, Martin RJ, Frank SH, Worley S, Sun Z, Hibbs AM. Pediatric specialists’ beliefs about gastroesophageal reflux disease in premature infants. Pediatrics. 2010;125(1):96-104. 22.Hegar B, Vandenplas Y. Gastroesophageal reflux: natural evolution, diagnostic approach and treatment. The Turkish Journal of Pediatrics. 2013;55:1-7. Acta Paul Enferm. 2014; 27(3):255-9. 259 Original Article Prevalence of burnout syndrome among resident nurses Ocorrência da síndrome de Burnout em enfermeiros residentes Kelly Fernanda Assis Tavares1 Norma Valéria Dantas de Oliveira Souza1 Lolita Dopico da Silva1 Celia Caldeira Fonseca Kestenberg1 Keywords Occupational health nursing; Education, nursing, graduate; Burnout, professional; Occupational health; Internship and residency Descritores Enfermagem do trabalho; Educação de pós-graduação em enfermagem; Esgotamento profissional; Saúde do trabalhador; Internato e residência Submitted March 6, 2014 Accepted May 26, 2014 Abstract Objective: To identify the prevalence of burnout syndrome among nursing residents. Methods: Cross-sectional study with 48 second-year nursing residents. The Maslach Burnout Inventory (MBI) was used for data collection, as well as a survey with sociodemographic variables. Results: Ten residents (20.83%) presented alterations in three dimensions of the inventory (Emotional Exhaustion, Depersonalization and Personal Accomplishment), which indicates a developing burnout syndrome. Conclusion: The occurrence of burnout syndrome was identified in the group of nursing residents, with the following determining factors: young and female individuals, single, childless, recently graduated and assigned to high-complexity sectors. Resumo Objetivos: Identificar a ocorrência da síndrome de Burnout em residentes de enfermagem. Métodos: Estudo transversal com 48 residentes de enfermagem do segundo ano. O instrumento de coleta de dados foi o Maslach Burnout Inventory e um formulário com as variáveis sociodemográficas. Resultados: Foram encontrados dez residentes (20,83%) com alterações em três dimensões (Exaustão Emocional, Despersonalização e Realização Profissional), sugerindo o desenvolvimento da síndrome. Conclusão: A ocorrência da síndrome de Burnout foi identificada no grupo de residentes de enfermagem, os quais apresentaram os seguintes fatores determinantes: indivíduos jovens, do gênero feminino, solteiros, sem filhos, recém-formados e inseridos em setores de alta complexidade. Corresponding author Norma Valéria Dantas de O. Souza. 28 de Setembro Avenue, 157, Vila Isabel, RJ, Brazil. Zip Code: 21551030 [email protected] DOI http://dx.doi.org/10.1590/19820194201400044 260 Acta Paul Enferm. 2014; 27(3):260-5. Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil. Conflicts of interest: there are no conflicts of interest to declare. 1 Tavares KF, Souza NV, Silva LD, Kestenberg CC Introduction Methods The term “burnout” has been coined to define a set of symptoms presented mainly by professionals who work with people – teachers, nurses and doctors, for example –, and who complain of physical and mental exhaustion, irritability, loss of interest in work and self-depreciation. Workers with burnout syndrome find that the meaning of their relationship with work is lost; work activities lose their importance; and any effort seems useless. These symptoms indicate an upcoming collapse, which occurs after all available energy is consumed.(1) In this perspective, it has been determined that burnout syndrome is a result of chronic work-related stress, with negative consequences to individual, professional, family, social and institutional spheres. Workers lose the ability to (re)adapt to the existing demands of the workplace.(1-3) Residency programs place recent graduates into the work market, providing them with an opportunity to gain professional experience and become specialists in their chosen area.(3,4) However, we must consider that this professional may present predisposing factors for developing physical and emotional fatigue. We must also consider other characteristics such as age, marital status, idealism, time in the profession, time in the institution, role conflict and lack of family support, which can increase vulnerability to burnout syndrome.(4) Nursing residents practice a profession geared towards the caring/helping of others. This is also an element which can lead to intense psychological suffering, for it means dealing with pain, suffering, death and unhappiness, as well as with the concerns and problems of other human beings.(2,4) Given this context, multiple factors act as possible causes of burnout syndrome among residents. In this light, the guiding question for our study was: What is the prevalence of burnout syndrome among resident nurses? Thus, the objective was to identify the prevalence of burnout syndrome among nursing residents. A cross-sectional study was carried out in a teaching hospital in Rio de Janeiro, a city located in the State of Rio de Janeiro, in the Southeast region of Brazil. Data were collected between July and September of 2011. The sample population consisted of 48 second-year nursing residents, assigned to the following programs: internal medicine (9), intensive care (7), clinical surgery (6), cardiovascular (5), nephrology (5), obstetrics (4), pediatrics (3), adolescent health (3), surgical center (2), psychiatry and mental health (2), neonatology (1) and worker’s health (1). We chose second-year nursing students to refrain from inducing the results towards positively scoring for burnout syndrome, for people who have less time in their workplace reality are more pre-disposed to develop the syndrome. We used the Maslach Burnout Inventory−General Survey for gathering data, as well a survey regarding sociodemographic and work characteristics. The data were charted on Excel, and logical and statistical functions were used to qualify and quantify the sociodemographic and work characteristics, in addition to the three dimensions of burnout syndrome. The results were analyzed in light of a literature review, emphasizing aspects regarding hospital work organization, burnout syndrome and content relative to the nursing residency. Cutoff points were calculated using percentiles and coefficients of variation for each dimension, analogous to the study of the group mentioned above. Thus, for Emotional Exhaustion we obtained ≥0.68 and ≤0.29 percentiles, which correspond to 27 and 20 points, respectively; for Depersonalization, we obtained ≥0.69 and ≤0.21 percentiles, represented by 11 and 3 points, respectively; and for Lack of Personal Accomplishment, ≥0.76 and ≤0.28 percentiles, which correspond to 32 and 24, respectively. The internal reliability of the instrument was measured using Cronbach’s alpha, which resulted in a value of >0.70. In other words, the Maslach Burnout Inventory obtained a coefficient of 0.7694, indiActa Paul Enferm. 2014; 27(3):260-5. 261 Prevalence of burnout syndrome among resident nurses cating reliability and good internal consistency. Thus, the reliability coefficient for the Emotional Exhaustion dimension was 0.8050, for Depersonalization 0.8287, and Personal Accomplishment 0.8227. The study complied with national and international guidelines for studies involving human research. Results The sample group presented the following sociodemographic characteristics: predominately female (91.66%), mean age of 26 years (standard deviation ±2.9), single (83.33%), childless (87.50%), from Rio de Janeiro (52.33%), living with their families (77.08%), having graduated 1 to 2 years before data collection (70.83%). Ten residents (20.83%) displayed alterations in all three dimensions (Emotional Exhaustion, Depersonalization and Personal Accomplishment), which are warning signs for the syndrome. This number was reached by calculating the sum of points obtained on the responses given by the 48 residents – cutoff points which did not take into consideration particular sociodemographic and occupational variables. The residents who presented such alterations in all three dimensions possessed the following sociodemographic characteristics: individuals with a mean age of 26 years, in the 23 to 33 age group, all female, single (90%) and childless (70%). Regarding their origin and place of residence, 80% were from the state of Rio de Janeiro and 77.77% lived with their family. It is also important to emphasize that the nursing residents who presented alterations in all three dimensions took an average of 1 hour and 12 minutes to commute to work, and 90% had graduated less than three years before the study. In other words, they were recent graduates. Regarding the participants that presented such alterations, 60% worked in specialized care units – 20% in the cardiovascular program and 40% in intensive care; the remaining residents were distributed among the surgical center (10%), internal medicine (10%), nephrology (10%) and obstetrics (10%). With respect to their work characteristics, 60% had taken temporary leaves of absence from work (up to 15 days) due to musculoskeletal disorders, stress, anxiety, herpes and labyrinthitis, among other pathologies. It is also significant that some individuals took leaves of absence for more than one disease and more than once throughout their time as nursing residents, up to the time of data collection. Although the number of residents with alterations in all three dimensions of burnout syndrome is not representative, several individuals presented scores close to the cutoff points used for classifying dimension alterations. In other words, 43.75% presented the medium-ranged values of Emotional Exhaustion, 37.50% presented the medium-ranged values of Depersonalization, and 66.6% had low values of Personal Accomplishment (Table 1), which led us to classify them as pre-disposed to develop the syndrome. Table 1. Result distribution of Maslach Burnout Inventory (MBI) dimensions n (%) Mean points (SD) Coefficient of variation Minimum Maximum High 16(33.33) 24(±7) 0.303 0.29 Medium 21(43.75) 8(±6) 0.746 28(±6) 0.223 MBI dimensions EE DE PA Low 11(22.91) High 16(33.33) Medium 18(37.50) Low 14(29.16) High 16(33.33) Medium Low Burnout syndrome 32(66.66) 10(20.83) SD - standard deviation; EE - Emotional Exhaustion; DE - Depersonalization; PA - Personal Accomplishment 262 Acta Paul Enferm. 2014; 27(3):260-5. Cronbach’s Alpha Cronbach’s Alpha (MBI) 0.68 0.805 0.7694 0.21 0.69 0.8287 0.28 0.76 0.8227 Cut of point Tavares KF, Souza NV, Silva LD, Kestenberg CC Upon conducting an individualized analysis of the cutoff points per variable, we found four other individuals (8.33%) with altered burnout dimensions scores. Thus, they were classified as being pre-disposed to develop the syndrome. These individuals possessed similar characteristics to those who displayed alterations for burnout in all three dimensions: they lived by themselves or with others; lived in other municipalities; took an average of 1 hour and 23 minutes to commute to work; and were assigned to surgical and adolescent health nursing programs. Discussion One limitation of this study was its cross-sectional design, which did not allow us to establish causal relations. The health of nursing residents deserves special attention, for we confirmed that they present vulnerability for mental illness. This confirmation was based on their profile and the data obtained in this study, which indicate that the participants possess characteristics that make them particularly susceptible to burnout. These results can lead to relevant points for teaching-learning institutions and worker health services to reflect upon, including prevention, detection and practices that minimize burnout syndrome in nursing residents. In light of the results described, we notice that there is a parallel with those found in the literature, which demonstrate that individuals with alterations indicating possible burnout possess similar susceptibility characteristics. Studies with nursing residents and physical therapy professionals found individuals who were young, female, single, childless and at the start of their professional career.(4,5) Another characteristic which deserves special mention is that, in addition to carrying out their professional work activities, residents also accumulate other academic activities, leading to stress and physical and mental fatigue. These include academic work, exams, term papers, and theoretical classes, among others.(5) Regarding the age group (23 to 33 years), results show that the group of residents displayed very sin- gular characteristics. In other words, they were, for the most part, recent graduates – with 1 or 2 years since graduation – and inserted in the work market. In this sense, they were possibly lacking in skills and practical experience, making them even more insecure or vulnerable to burnout. In this perspective, limited time of professional experience and young age can influence their health, for events such as graduating and entering the work market usually generate stress. They are new experiences, which are unfamiliar and can cause fear.(1) Thus, the recent graduate does not usually have the tools for dealing with the tensions of the working world. Therefore, this is a relevant variable for a deeper understanding of the issue at hand. Corroborating this analysis, we infer that the more skills, competence and confidence acquired with time of professional practice, the higher the possibility of dealing with stressful situations. In turn, the chances for developing chronic stress and burnout syndrome are reduced.(6) Another noteworthy variable is gender. These results are very similar to those of other studies conducted with nursing professionals, which demonstrate that women are more inclined to develop burnout. This profession is represented eminently by women, and in an androcentric world, women still suffer from disadvantages, such as taking on other tiring and stressful unpaid work shifts−, at home with domestic chores and raising children.(2,7,8) Studies have demonstrated that marital status and number of children can act as protective factors for the syndrome.(3) Our results indicate that the nursing residents who were developing burnout were predominately single and childless, thus corroborating their susceptibility to the syndrome. Studies infer that having a partner with whom to share life and work problems is a significant protective factor against psychological suffering and, consequently, mental illness.(2,3) The resident’s place of origin was a relevant data for analysis, for most out-of-state residents left their hometowns to specialize in their given residency program. Thus, it is common for them to live by themselves or with others throughout the program. This is a determining factor for reActa Paul Enferm. 2014; 27(3):260-5. 263 Prevalence of burnout syndrome among resident nurses duced affective relationships, which corroborates the possibility of psychological suffering. Furthermore, adapting to other customs and even different cultures (considering the size of Brazil and the different colonizing populations) can lead to stress and burnout vulnerability.(3) More relevant data is obtained when considering the specialized units of care chosen by residents. Other studies have also found that the intensive care and the cardiovascular nursing units present the highest incidence of residents with the burnout.(4,5) Residency programs in intensive care units have their particularities, for they involve caring for chronic and/or severely ill patients, which require specialized techniques and different types of procedures. Furthermore, more time availability is required in order to care for the needs of these patients. On the other hand, residents are frequently responsible for providing direct care to the more severely ill patients, which requires a higher set of skills (psycho-cognitive and motor). Such responsibility can translate into psychological suffering due to lack of professional experience.(4) Nonetheless, residents assigned to other work contexts possess characteristics which are equally relevant to burnout, for they are inserted in a high-complexity teaching hospital, considered a training center of human resources and technology development in the health field. This means that residents carry out multiple and refined activities, which requires that the professional continuously adapt to the characteristics of this work environment, an exhaustive process of inner psychological organization and re-organization. (9) This can also be considered an important variable which favors psychosomatic illness and lead to burnout syndrome. With respect to the data found on illness-related work leaves, a high percentage of individuals reported taking leaves of absence. The reasons for these medical leaves were diseases related to stress and psychological suffering.(6) Musculoskeletal disorders are diseases caused by physical and mental overload; oral herpes frequently emerges in stressful situations, as well as labyrinthitis. Thus, our results corroborate those found in the literature.(8) Another important result regards the individuals with a pre-disposition for developing burnout, who 264 Acta Paul Enferm. 2014; 27(3):260-5. presented high scores on Emotional Exhaustion, Depersonalization, and low scores on Personal Accomplishment, but who did not make the cutoff score which characterizes the full syndrome. Nonetheless, these variations are of significant relevance, for in different circumstances, these individuals can maintain, reduce or increase their scores in each dimension. This variance occurs because burnout syndrome involves multiple factors, both dynamic and multifaceted.(2,9) Therefore, if the individual who is inclined to develop the syndrome is transferred to another sector or meets a partner with whom to share their moments of suffering, these can act as protective factors against burnout, thus reducing their MBI scores. However, high Emotional Exhaustion scores can suggest a syndrome in the making, for it is one of the initial signs of burnout. This dimension usually results from overload and personal conflict in interpersonal relationships.(3,5) Emotional Exhaustion is also a predictor of Depersonalization, which in turn is a predictor for lower Personal Accomplishment. Thus, such resident can go from being pre-disposed to burnout to presenting significant alterations for developing the full syndrome. Conclusion The present study found individuals developing burnout and uncovered others pre-disposed to the syndrome among a group of nursing residents. Being young, female, single, childless, and at the start of a professional career, as well as being assigned to high-complexity residency programs (cardiovascular and intensive therapy) were found to be predisposing factors for burnout syndrome in a group of nursing residents. Acknowledgements The authors thank the Solução Estatística Júnior (SEJ) University Outreach Project of Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil. Collaborations Tavares KFA contributed with the study’s conception and design, data collection, statistical treatment of Tavares KF, Souza NV, Silva LD, Kestenberg CC data, data analysis and interpretation; drafting of the article and final approval of the version to be published. Souza NVDO collaborated with the study’s conception and design, drafting of the article, critical review for important intellectual content and final approval of the version for publication. Silva LD cooperated with the conception and design, critical revision of the relevant intellectual content and final approval of the version to be published. Kestenberg CCF participated in data analysis and interpretation, critical review for important intellectual content and final approval of the version to be published. References 1. Franca FM, Ferrari R, Ferrari DC, Alves ED. [Burnout and labour aspects in the nursing teams at two medium-sized Hospitals]. Rev Latinoam Enferm. 2012;20(5):961-70. Portuguese. 2. Meneghini F, Paz AA, Lautert L. [Occupational factors related to burnout syndrome components among nursing personnel]. Texto & Contexto Enferm. 2011; 20(2):225-33. Portuguese. 3. Silva TL, Benevides-Pereira AM, França IS, Alchieri JC. [Sociodemographic aspcsts related to burnout syndrome in physiotherapists]. Revistainspirar. 2010; 2(1):6-13. Portuguese. 4. Franco GP, Barros AL, Norgueira-Martins LA, Zeitoun SS. [Burnout in nursing residents]. Rev Esc Enferm USP. 2011; 45(1):12-8. 5. Guido LA, Silva RM, Goulart CT, Bolzan ME, Lopes LF. [Burnout syndrome in multiprofessional residents of a public university]. Rev Esc Enferm USP. 2012; 46(6):1477-83. Portuguese. 6. Benevides-Pereira AT, Yamashita D, Takahashi RM. [About the educators, how are they?]. REMPEC - Ensino, Saúde e Ambiente. 2010; 3(3):151-70. Portuguese. 7. Goulart CT, Silva RM, Bolzan ME, Guido LA. Sociodemographic and academic profile of multiprofessional residents of a public university]. Rev Rene. 2012; 13(1):178-86. Portuguese. 8. Mauro MY, Paz AF, Mauro CC, Pinheiro MA, Silva VG. [Working conditions of the nursing team in the patient wards of a university hospital]. Rev Esc Anna Nery. 2010;14(2):244-52. Portuguese. 9. Ferreira RE, Souza NV, Gonçalves FG, Santos DM, Pôças CR. [Nursing work with customers HIV/AIDS: psychic potential for suffering]. Rev Enferm UERJ. 2013; 21(4):477-82. Portuguese. Acta Paul Enferm. 2014; 27(3):260-5. 265 Original Article Compliance with outpatient clinical treatment of hypertension Adesão ao tratamento clínico ambulatorial da hipertensão arterial sistêmica Aurelina Gomes e Martins1 Suzel Regina Ribeiro Chavaglia2 Rosali Isabel Barduchi Ohl3 Igor Monteiro Lima Martins4 Mônica Antar Gamba3 Keywords Patient compliance; Hypertension/ therapy; Blood pressure monitoring, ambulatory; Primary care nursing; Patient acceptance of health care Descritores Cooperação do paciente; Hipertensão/ terapia; Monitoração ambulatorial da pressão arterial; Enfermagem de atenção primária; Aceitação do paciente de cuidados de saúde Submitted March 13, 2014 Accepted May 29, 2014 Corresponding author Rosali Isabel Barduchi Ohl Napoleão de Barros street, 754, São Paulo, SP, Brazil. Zip Code: 04024-002 [email protected] Abstract Objective: Assessing the compliance with outpatient treatment of hypertension. Methods: Cross-sectional study in which were studied demographic and socioeconomic variables, as well as of knowledge about the disease. The Morisky-Green Test (MGT) was applied to measure the compliance with treatment, and multiple logistic regression to identify factors associated with it. Results: There was homogeneity between compliance/non-compliance regarding gender, age, marital status, color/race, education, professional activity, number of people in the household and occupation. There was a significant association between income and compliance with treatment (p = 0.039). The hypertensive subjects guided by the community health agents had 2.21 times greater risk of non-compliance with medication compared to those guided by the team and adjustment to income of the subjects non-compliant with medication (OR = 2.21, CI 1.08 -4, 85, p = 0.033). Conclusion: Income and the guidance provided by community health agents interfered in the compliance with treatment, requiring training and the offer of fundraising practices and lifestyle changes. Resumo Objetivo: Analisar adesão ao tratamento clínico ambulatorial da hipertensão arterial. Métodos: Estudo transversal, onde foram estudadas variáveis demográficas, socioeconômicas e de conhecimento sobre a doença. Aplicou-se Teste de Morisky-Green (TMG) para medir adesão, e regressão logística múltipla, identificando os fatores associados à adesão. Resultados: Observou-se homogeneidade entre adesão/não adesão quanto ao sexo, faixa etária, estado civil, cor/raça, escolaridade, atividade profissional, número de pessoas na casa e ocupação. Evidenciou-se associação significativa entre renda e adesão ao tratamento (p=0,039). Os hipertensos orientados pelos agentes comunitários de saúde apresentaram 2,21 vezes mais chance de não adesão à medicação quando comparados aos orientados pela equipe e ajustados a renda de não/adesão à medicação (OR= 2,21; IC 1,08 -4,85; p=0,033). Conclusão: A renda e as orientações prestadas pelos agentes comunitários de saúde interferiram na adesão, havendo necessidade de capacitação e oferecimento de práticas de captação de renda e mudança de hábitos. Universidade Estadual de Montes Claros, Montes Claros, MG, Brazil. Escola de Enfermagem, Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brazil. 3 Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil. 4 Faculdades Integradas Pitágoras de Montes Claros, Montes Claros, MG, Brazil. Conflicts of interest: no conflicts of interest to declare. 1 2 DOI http://dx.doi.org/10.1590/19820194201400045 266 Acta Paul Enferm. 2014; 27(3):266-72. Martins AG, Chavaglia SR, Ohl RI, Martins IM, Gamba MA Introduction Systemic hypertension is correlated to clinical complications that lead a significant number of Brazilians to die. Many complications could have been avoided and/or minimized, such as acute myocardial infarction, cerebrovascular accident and kidney failure, with precocious compliance with a treatment plan.(1) The rates are alarming and account for a major cause of death in the country. The mortality rate from diseases of the circulatory system is increasing every year. Between the years of 2000 and 2011, the number of deaths increased by 28.6% and in 2011, ischemic heart diseases and cerebrovascular diseases accounted for 61% of deaths in this category. In addition, cardiovascular diseases are responsible for sequelae and complications that impair the performance of these citizens in their own lives, in the lives of their families and ultimately in society as a whole.(2,3) Studies indicate that low compliance with treatment is present in 50% of cases of decompensated hypertensive patients and this fact has been as a barrier to blood pressure control in this population.(1,4) An important factor for determining interference in care for people with chronic diseases is related to the terms adherence and compliance. Although interconnected and relating to the same action, they differ because they indicate the act (compliance) and the effect (adherence) of this action. Thus, compliance with treatment of a disease means to follow the treatment exactly as proposed by health professionals. (4) It is important to conduct studies on the subject of compliance that identify the influences of human behavior and the socioeconomic structure for non-compliance with a treatment regimen for hypertension considered relatively simple and sustained on the triad of medication, balanced diet and physical activity. Thus, specific interventions can be made in the monitoring of this population, such as enforcing public health programs and establishing quality indicators, and then evaluate those programs. The aim of this study was to assess the compliance with clinical treatment of hypertension in the population assisted by a unit of the Family Health Strategy (ESF - Estratégia de Saúde da Família). Methods This is a cross-sectional study carried out in a unit of the Family Health Strategy in the city of Montes Claros, Minas Gerais, southeastern Brazil. Initially, was used the Clinical Management System of Hypertension and Diabetes Mellitus of the Primary Care (SIS-HIPERDIA - Sistema de Gestão Clínica de Hipertensão Arterial e Diabetes Mellitus da Atenção Básica). In total, participated of the study 140 people in outpatient treatment for arterial hypertension and residents of the covered area. It was a non-probabilistic sample, and those with comorbidities were excluded. The used instruments were related to socio-clinical and epidemiological variables, linked to the Morisky-Green test validated in Brazil, which assesses the attitudes of patients about the drug treatment of hypertension.(5) Variables related to the object of the study were presented using descriptive statistics. The Pearson’s Chi-squared test or the Fisher’s exact test were used for the comparison between compliance with treatment and the other variables. In multivariate analysis, the dependent variable of the research was non-compliance with treatment. The associations between the dependent variable and the study variables - socioeconomic, demographic, of lifestyle and knowledge of the disease - were established by the Pearson’s chi-squared test or the Fisher’s exact test. In order to verify the factors associated with non-compliance with treatment, was used the multivariate logistic regression. Measures of risk and odds ratio (OR) were estimated for each variable individually in the model (crude OR), and also the adjusted OR by the multiple regression model. In all statistical tests was considered a significance level of 0.05. The statistical proActa Paul Enferm. 2014; 27(3):266-72. 267 Compliance with outpatient clinical treatment of hypertension gram used was the Statistical Package for Social Science (SPSS), version 14.0. The development of study followed the national and international standards of ethics in research involving human beings. Results Among the 140 investigated subjects, the majority are female (70.7%), aged between 40-49 years (42.1%), unmarried (50%). Regarding color/race, the highest proportion was declared as non-white (70.7%). With regard to education, 94 people (67.1%) reported having completed the primary education, 17.1% were illiterate, and 15.8% had attended high school or college. With regard to occupation, the majority, or 98 subjects (70%) were classified as not economically active, being away from work or retired. A total of 119 (85%) subjects had a family income of only a minimum wage, 108 (77.1%) subjects resided in homes with fewer than five residents. In relation to the condition of property 108 (77.1%) reported living in their own house. Analyzing both groups of compliance and non-compliance with antihypertensive treatment and the demographic variables, similarities are observed between the two regarding gender, age, marital status, and race/color (Table 1). Table 1. Demographic characteristic and compliance with treatment Compliance Variables Yes n(%) No n(%) p-value 0.222 Gender Male 15(36.6) 26(26.3) Female 26(63.4) 73(73.7) Age (years) < 50 34(82.9) 75(75.8) ≥ 50 07(17.1) 24(24.2) 0.353 Marital status Married 05(12.2) 10(10.1) Unmarried 36(87.8) 89(89.9) 0.767 Color/Race White 10(24.4) 21(21.2) Non-white 31(75.6) 78(78.8) 41(100.0) 99(100.0) Total 268 Acta Paul Enferm. 2014; 27(3):266-72. 0.680 The groups are also similar with respect to education, occupation, number of people in the house and condition of employment. However, a significant association was found between the income and compliance with treatment (p = 0.039), demonstrating heterogeneity in relation to this variable (Table 2). Table 2. Socioeconomic characteristic and compliance with treatment Compliance Variables Yes n(%) No n(%) p-value Iliterate 5(12.2) 19(19.2) 0.553 Primary school 30(73.2 64(64.6) Secondary school or higher 06(14.6) 16(16.2) Yes 14(34.1) 28(28.3) No 27(65.9) 71(71.7) Education Profissional activity 0.491 Family income < 1 minimum wage 09(22.0) 09(9.1) ≥ 1 minimum wage 32(78.0) 90(90.9) < 5 people 32(78.0) 21(21.2) ≥ 5 people 09(22.0) 78(78.8) Owner 30(73.2) 76(76.8) Not owner 11(26.8) 23(23.2) 41(100.0) 99(100.0) 0.039 Number of people 0.870 Condition of housing Total 0.471 The hypertensive groups of compliance and non-compliance with treatment were similar with respect to the guidance, the Body Mass Index BMI and changes in habits after the guidance. In relation to body mass index - BMI, 114 (81.4%) people are classified between overweight and obesity (84%), reporting to have received guidance on diet (88.6%), physical activity (84.3%), cigarette smoking (62.9%) and alcohol (60.0%), and also on the use of medicines (96.4%). In relation to the guidance received, the majority, or 94 (67.1%) subjects reported the Community Health Agent as responsible for it. Regarding knowledge of the disease, it was observed that the groups were homogeneous for the following variables: time of diagnosis, treatment time, attendance to medical appointments and receipt of home visits (Table 3). As for the distribution of non-compliance with treatment by hypertensive subjects associated with exclusive guidance given by the Communi- Martins AG, Chavaglia SR, Ohl RI, Martins IM, Gamba MA Table 3. Knowledge about the disease Compliance Variables Yes n(%) No n(%) p-value <9 26(63.4) 62(62.6) 0.930 ≥ 9 15(36.6) 37(37.4) Time of diagnosis (years) Treatment time (years) <9 25(61.0) 61(61.6) 9 |– 10 16(39.0) 38(38.4) 0.944 Attendamce to appointments Yes 39(95.1) 85(85.9) No 2(4.9) 14(14.1) Yes 39(95.1) 95(96.0) No 2(4.9) 4(4.0) 0.150 Receive home visits 1.000 Compliance with treatment (self-reported) Yes 41(100.0) 69(69.7) No 0 30(30.3) 41(100.0) 99(100.0) Total - ty Health Agent (ACS – Agente Comunitário de Saúde), the hypertensive were 2.21 times more likely of ‘non-compliance’ with treatment compared to those not advised by the Community Health Agent, regardless of family income, use of drugs and cigarettes. (Crude OR 95% CI (1.08 - 4.91) adjusted OR (95% CI) = 2.21 (1.08 - 4.85; p = 0.033), The p-value of the adjustment model test (Hosmer & Lemeshow) is 0.94 in the model adjusted to household income, use of drugs and cigarettes, and in the model without adjustment variable. Discussion This research with descriptive analysis obtained by a cross-sectional study has some limitations related to selection bias, i.e., because the data were collected in a single unit of health as well as based on self-reported information, it does not allows us to make generalizations regarding compliance with treatment by hypertensive people registered in other services. Compliance with treatment of chronic conditions is a major challenge for public health and nursing. Thus, the results of this study may help nurses with defining strategies, as carrying out new researches and educational interventions that contribute to increase the effectiveness of actions taken to control hypertension. The largest portion of the study population is female. The prevalence of hypertension in the female population has been suggested by some studies carried out in Brazil and abroad, reflecting the increased demand of this population for health services. In Brazil, this fact may be related to the increased availability of women to participate in activities developed in health services, in particular in the Family Health Strategy.(6-9) Studies point to the fact that women seek treatment as a cultural reflection motivated by how the health services are organized (opening hours, location), and the higher life expectancy of women compared to men, which is attributed to cardiovascular protection and the lower consumption of tobacco and alcohol.(10-12) The most common age in the study population was the range between 40 and 49, different from information found in the literature, which indicates that hypertension is prevalent in the male population of around 50 years old, and equating the female population after menopause.(6,7,11,12) This was observed in this study because it was based on record data rather than population survey, characterizing as a possible selection bias. Regarding the level of education, in this study predominated the complete elementary education, an important social indicator and determinant factor in the health-disease process. Despite not having found a significant association between education and compliance with treatment, the literature shows a falling trend in mean blood pressure and hypertension with higher levels of education, considering that the influence of other social factors and conditions of occupation may occur.(13,14) Individuals with lower education and chronic diseases have difficulties in understanding both the prescription as the information obtained in the drug leaflet regarding the correct dosage, indications, contraindications and warnings, since these limitations of understanding increase the risk of errors with medication.(15,16) Regarding marital status, individuals classified as ‘separated’ had a higher frequency of hypertension. We can infer that the formal or informal support Acta Paul Enferm. 2014; 27(3):266-72. 269 Compliance with outpatient clinical treatment of hypertension that people receive from their partners may improve compliance with treatment. People with companions are two times more likely to comply with treatment compared to those without partners.(17) As for the color/race, most participants consisted of non-whites. Studies that approach gender and color in Brazil show a predominance of black women with hypertension by up to 130% compared to white and that, in Brazil, the impact of miscegenation on the disease is not known with accuracy.(4,18) The significant association (p = 0.039) found between non-compliance with treatment and financial resources can be corroborated by studies indicating that the low purchasing power not only hinders survival but also the access to antihypertensive medications. In this sense, it is observed in the literature that lower economic levels had higher prevalence of hypertension and exposure to risk factors for increasing blood pressure.(4,6,7,10,19) The compliance with treatment is considered a complex behavioral process strongly influenced by the environment, individuals, health care professionals and health care, covering the biological, psychological, socioeconomic and cultural dimensions. It is observed that both the received health guidance as the habits and living conditions like excess weight, alcohol intake, smoking, poor diet, and stress, among others, constitute risk factors for non-maintenance of blood pressure control.(1,2,19,20) By analyzing the distribution of hypertensive subjects according to the guidance received on health and lifestyle habits, it was observed that the majority (81.4%) mentioned having obtained information on diet, physical activity, smoking and alcohol intake. These subjects signaled changes in their lifestyle habits after receiving such information. The effect of educational programs on compliance with drug treatment indicates low compliance with these recommendations by the studied population. Education constitutes one of the most successful interventions to improve compliance and self-management of people with chronic diseases, especially if the educational program is centered on the beliefs and concerns about their conditions of health and treatment. 270 Acta Paul Enferm. 2014; 27(3):266-72. Hence the need for a greater number of investigations about the self-reported change in habits, in order to assess the effectiveness and quality of guidance given by health professionals.(21-25) Regarding the distribution of hypertensive subjects according to treatment time, attendance to medical appointments, receipt of home visits and self-reported compliance, it is observed that those who report themselves as non-compliant, in majority, have time of diagnosis and treatment time of less than nine years. These are the people who attend consultations more often and receive home visits. These data are similar to the results shown by studies on the subject of compliance with treatment and control of hypertension, as well as the fragility of self-reported data by study subjects in research.(26,27) There was a statistically significant relationship (p <0.05) between the non-compliance with treatment when the health guidance was given by the community health agent only. This may be linked to the short time of activity that these professionals have in this area without any training or qualification. These findings are consistent with another study indicating that the process of qualification of health agents has been fragmented and insufficient to develop the necessary skills for preventive health actions and insertion in the line of care of hypertension.(28,29) The Morisky-Green test showed low compliance with drug therapy for the treatment of hypertension (70.7%), a fact mainly related to forgetting to take doses of medication. Similar results were found in observational studies that demonstrated the lack of compliance of hypertensive patients associated with forgetfulness in the ingestion of medication.(18,22) When asked about the reason for non-compliance, 30 (21.4%) subjects cited the lack of medicines in the unit as a cause. In Brazil, despite representing a large part of investment in public health, the free dispensing of medicines is still not enough to cover the current needs. Thus, it is necessary to invest in improving the quality of care offered to the population, improving user embracement, increasing the resolutivity across the entire network of services, encouraging account- Martins AG, Chavaglia SR, Ohl RI, Martins IM, Gamba MA ability of health professionals and staff for the care of patients, and integrating services through lines of care and greater coordination among the various levels of the local health system.(30) The lack of training of community workers in the survey and in meeting the needs of hypertensive patients indicates the importance of developing strategies and professional training that enable the knowledge and application of lines of care for hypertension, in order to improve the quality of primary care provided. Conclusion The income and the guidelines provided by community health workers were significant factors for adherence to the recommended treatment. Collaborations Martins AG; Chavaglia SRR; Ohl RIB; Martins IML and Gamba MA declare to have contributed to the conception and design, analysis and interpretation of data, drafting the article, critical revision of the important intellectual content and final approval of the version to be published. References 1. Piccini R, Facchini LA, Tomasi E, Siqueira FV, Silveira DS, Thumé E, Silva SM, Dilelio AS. Promoção, prevenção e cuidado da hipertensão arterial no Brasil. Rev Saúde Pública. 2012; 46(3):543-50. 2. Brasil. Ministério da Saúde. Rede interagencial de informações para a saúde. DATASUS. [Internet] 2011; [citado 2012 Out 12]. Disponível em http://tabnet.datasus.gov.br/cgi/idb2011/matriz.htm. 3.Sociedade Brasileira de Cardiologia; Sociedade Brasileira de Hipertensão; Sociedade Brasileira de Nefrologia. 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Brasília: Organização Pan-Americana da Saúde; 2010. 232 p. Original Article Nasal colonization by Staphylococcus sp. in inpatients Colonização nasal por Staphylococcus sp. em pacientes internados Gilmara Celli Maia de Almeida1 Nara Grazieli Martins Lima1 Marquiony Marques dos Santos1 Maria Celeste Nunes de Melo2 Kenio Costa de Lima2 Keywords Nursing service, hospital; Clinical nursing research; Nursing care; Nasal mucosa/microbiology; Staphylococcus; Nasopharynx/microbiology; Inpatients Descritores Serviço hospitalar de enfermagem, Pesquisa em enfermagem clínica; Cuidados de enfermagem; Mucosa nasal/microbiologia; Staphylococcus; Nasofaringe/microbiologia; Pacientes internados Submitted April 2, 2014 Accepted May 26, 2014 Corresponding author Gilmara Celli Maia de Almeida Rua André Sales, 667, Campus Caicó, Caicó, RN, Brazil. Zip Code: 59300-000 [email protected] DOI http://dx.doi.org/10.1590/19820194201400046 Abstract Objective: To analyze nasal colonization by Staphylococcus sp. its resistance to methicillin, and associated factors in inpatients. Methods: Nasal sample collection, antimicrobial susceptibility tests, and analysis of medical records of inpatients (n=71) were performed, and a questionnaire was applied. Data were analyzed by descriptive and inferential statistics using the chi-square, Student’s t, and Mann-Whitney tests (α=5%). Results: Nearly half (44.4%) of the patients who were significantly associated with prolonged antibiotic treatment (p=0.02) was infected with methicillin-resistant Staphylococcus sp.. A significant association was observed between patients with sensitive strains and absence of antibiotic treatment prior to sample collection (p=0.02) or absence of wounds (p=0.003). Conclusion: Strains of methicillin-resistant Staphylococcus sp. were found, and there was no significant difference between the S. aureus species and the coagulase-negative Staphylococci groups, which indicates the degree of spread of methicillin resistance among different species of Staphylococcus. Resumo Objetivo: Analisar a colonização nasal por Staphylococcus sp., sua resistência à meticilina e fatores associados em pacientes internados. Métodos: Foram realizados coleta de amostra nasal, testes de susceptibilidade antimicrobiana e análise de prontuários médicos de pacientes internados (n=71), e foi aplicado um questionário. Os dados foram analisados por meio de estatística descritiva e inferencial usando os testes c2, t de Student e Mann-Whitney (α=5%). Resultados: Cerca de metade (44,4%) dos pacientes, significativamente associados ao tratamento antibiótico prolongado (p=0,02) estavam infectados por Staphylococcus sp resistentes à meticilina. Observou-se uma associação significativa entre pacientes com cepas sensíveis e ausência de tratamento com antibiótico antes da coleta (p=0,02) ou ausência de feridas (p=0,003). Conclusão: Foram encontradas cepas de Staphylococcus sp. resistentes à meticilina e não houve diferença significativa entre a espécie S. aureus e os grupos de estafilococos coagulase negativos, o que indica o grau de disseminação da resistência à meticilina entre diferentes espécies de Staphylococcus. Universidade do Estado do Rio Grande do Norte, Caicó, RN, Brazil. Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil. Conflicts of interest: no conflicts of interest to declare. 1 2 Acta Paul Enferm. 2014; 27(3):273-9. 273 Nasal colonization by Staphylococcus sp. in inpatients Introduction Excessive use of antimicrobial agents or inappropriate empirical treatment have contributed to the growing number of infections by multi-resistant microorganisms in both the community and hospital environment.(1) As a result, the treatment of patients with these infections is becoming more complex, greatly increasing the costs of both hospitalization and treatment of these patients in public hospitals. (2) Staphylococcus sp., mainly S. aureus, is commonly found in the skin and mucosa of humans (especially in the anterior region of the nasal passages), being among the microorganisms most resistant to antibiotics.(3) It is one of the main pathogens that colonizes healthy individuals in the community, leading to infection in patients admitted in hospitals.(4,5) In this context, it is worth emphasizing the worldwide increase in the prevalence of methicillin-resistant S. aureus (MRSA).(6) This agent causes serious infections, whether in hospitalized individuals or otherwise, emphasizing the importance of epidemiological vigilance in detecting development of resistance in both the community and in health care services.(6) In addition, coagulase-negative Staphylococci (CoNS) act as a reservoir of resistance genes, although these microorganism are less virulent. The presence of methicillin-resistant coagulase-negative Staphylococci (MRCoNS) in hospital environments can lead to the emergence of MRSA.(7,8) Presence of MRSA or MRCoNS in asymptomatic patients is a major source of contamination. Their early identification can reduce the risk of colonization of patients and cross-transmission between patients and health professionals, especially in hospital environment.(7,9) Although this theme is important, it has been little studied in the northeast of Brazil, especially in interior municipalities, which are characterized by marked social and economic inequality and where a large part of the population live in conditions of social deprivation. Therefore, studies in this region are necessary to support implementation and monitoring of measures of control to both minimize the potential spread of this microorganism and subsequently reduce the risk of hospital infections.(10) 274 Acta Paul Enferm. 2014; 27(3):273-9. Thus, the aim of this study was to describe nasal colonization by Staphylococcus sp., especially S. aureus, their respective sensitivity to methicillin, and associated factors in patients in a referral hospital in the interior of northeast Brazil. Methods A cross-sectional study was performed in the Hospital Regional do Seridó, in Caicó, Rio Grande do Norte (RN), a municipality in northeast Brazil. This hospital is a referral institution in the interior of RN, where patients from more than 14 municipalities are treated. Due to many reasons, there is a lack of research studies in hospital in the interior of northeast Brazil. Furthermore, this region has some of the lowest social and economic indicator scores in the country,(11) making investigation more difficult, especially if it requires laboratory and infrastructure support. Patients admitted to the medical and surgical clinics, and Intensive Care Unit (ICU) of the Hospital Regional do Seridó participated in the study. The subjects were enrolled in parallel with another study, in which the investigators aimed to identify Staphylococcus aureus in wounds of patients. This study included individuals with skin sores or wounds on the day of collection, or those without wounds who were hospitalized within 12 hours prior to collection. Individuals without wounds were accompanied during hospitalization to verify if pressure ulcers or post-surgical infections developed while they were in the hospital. Nasal collection was performed in patients included in the study described above in order to verify if there was colonization by Staphylococcus sp. Only the first 30 patients were considered for calculation of sample size. In the first analysis, 74% of Staphylococcus sp. isolated in the nostrils of patients hospitalized were found. We assumed a margin of error of 15%, a design effect of 1%, and a non-response rate of 20% to estimate the sample size (71 patients). Therefore, subjects were included until the sample size was complete (n=71) to characterize nasal Almeida GC, Lima NG, Santos MM, Melo MC, Lima KC colonization by Staphylococcus sp.. Data were collected during the first semester of 2012. Medical records were consulted in order to describe the factors related to the hospitalization/antibiotic treatment of the studied population. In addition, the patients completed a questionnaire containing questions related to age, gender, municipality of origin, presence of comorbidities or systemic impairment, and use of antibiotics prior to hospitalization, among other factors that could influence the frequency of methicillin-resistant Staphylococcus sp.. Samples from the nasal mucosa of patients were collected using a sterile swab soaked in 0.85% saline. For each patient, the swab was inserted into both nasal cavities and the sample was then placed in sterile tubes containing Brain Heart Infusion (BHI) broth (with 7.5% NaCl), which were then packed in styrofoam boxes with crushed ice and transported to the microbiology laboratory of the university. The samples were incubated in the laboratory (37 °C; 24 h). After this period, the samples were inoculated in mannitol salt agar medium and grown in a bacteriological incubator (37 °C; 48 h). The staphylococcal colonies were then subjected to Gram stain, catalase, and free coagulase tests. Samples positive for Gram, catalase, and coagulase were classified as Staphylococcus aureus; samples negative for coagulase test were classified as coagulase-negative Staphylococcus (CoNS). All samples identified as Staphylococcus sp. were submitted to antibiogram analysis using the disk diffusion method to verify their resistance to methicillin. The Chi-square or Fisher’s exact test were utilized to verify the association between dependent (resistance or sensitivity to methicillin and presence of S. aureus or CoNS) and qualitative independent variables. The Prevalence Ratio (PR) was utilized to analyze the degree of association. The Student’s t-test was utilized to ascertain whether there was a significant difference between the groups of dependent variables in relation to the patients’ age. The other quantitative independent variables (number of days of antibiotic use prior to sample collection, number of days of hospitalization, and number of hospitalizations in the last year) were analyzed using the Mann-Whitney test. A significance level of 5% was used with the Stata 10.0 statistical software. The development of the study met the national and international standards of ethics in research involving human beings. Results A total of 38 (53.5%) patients were female and 33 (46.5%) were male. Patients had a mean age of 63±21 (standard deviation, sd) and time of formal education of 3.8±3.7 years (sd). A total of 40 (56.3%) patients were in the medical clinic, 20 (28.2%) patients were in the surgical clinic, and 11 (15.5%) in the ICU. Wounds (n=23; 32.4%), fractures or surgery (n=8; 11.3%), and renal or post-surgical infections (n=8; 11.3%) were the most frequent reasons for hospitalization. As shown in table 1, 63 (88.8%) patients had Staphylococcus sp. (either S. aureus or CoNS) in their nostrils. Among the 11 patients who died, four (36.4%) had S. aureus and five (45.4%) had CoNS in their nostrils; in the samples from two (18.2%) of them, no bacteria grew or was identified as staphylococci. Among the resistant strains, the antibiogram for Staphylococcus sp. showed that seven (25%) were S. aureus and 21 (75%) were CoNS. However, this difference was not statistically significant (p=0.45). The general descriptive results for resistance/sensitivity of Staphylococcus sp. to methicillin, without specifying species or group, is shown in table 1. Table 1. Absolute and percent distribution, identification, and behavior of nasal Staphylococcus sp. relative to methicillin Dependent variables n(%) Presence of nasal Staphylococcus sp S. aureus 20(28.8) Coagulase-negative Staphylococcus 43(60.6) No growth of Staphylococcus or bacteria 8(11.3) Behavior of Staphylococcus sp. relative to methicillin Resistant 28(44.4) Susceptible 35(55.6) Behavior of S. aureus relative to methicillin Resistant Susceptible 7(9.9) 64(90.1) Acta Paul Enferm. 2014; 27(3):273-9. 275 Nasal colonization by Staphylococcus sp. in inpatients Of the 7 samples of nasal MRSA, 71.4% were found in patients from the medical clinic and 28.6% in patients from the surgical clinic or ICU. The patients with MRSA had some kind of systemic impairment (71.4%), diabetes (28.6%), suffered from cancer (28.6%), and had been hospitalized in the previous year (57.1%). Most patients (57.1%) were from a municipality with more than 60,000 inhabitants and 28.6% had died. Data in table 2 allow identifying an association between dependent and independent variables. A statistically significant association was found only with antibiotic resistance, prior use of antibiotics, and presence of wounds. The difference between groups of dependent variables and quantitative variables can be seen in table 3. A statistically significant difference was found only between antibiotic resistance and number of days of use of antibiotics prior to sample collection. Table 2. Patient characteristics associated with presence of Staphylococci (CoNS and S. aureus) into the nostril and their susceptibility to methicillin Susceptibility to methicillin Characteristics Resistant No resistant n(%) n(%) Staphylococcus sp S. aureus CoNS n(%) n(%) PR 95%CI p-value 11(37.9) 18(62.1) 1.02 0.58-1.77 0.95 9(26.5) 25(73.5) 10(28.6) 25(71.4) 2.00 1.04-3.84 0.02 10(35.7) 18(64.3) 9(27.3) 24(72.7) 11(36.7) 19(63.3) 13(29.5) 31(70.5) 7(36.8) 12(63.2) 13(35.1) 24(64.9) 7(26.9) 19(73.1) 14(27.5) 37(72.5) 6(50.0) 6(50.0) PR 95%CI 1.43 0.69-2.97 0.80 0.39-1.65 0.74 0.36-1.54 0.80 0.38-1.69 1.30 0.60-2.82 0.55 0.27-1.13 p-value Gender Male 13(44.8) 16(55.2) Female 15(44.1) 19(55.9) 0.33 Use of antibiotics prior to sample collection Yes 20(57.1) 15(42.9) No 8(28.6) 20(71.4) Yes 15(45.5) 18(54.5) No 13(43.3) 17(56.7) Yes 25(56.8) 19(43.2) No 3(15.8) 16(84.2) Caicó 14(37.8) 23(62.2) Other city 14(53.8) 12(46.2) Yes 25(49.0) 26(51.0) No 3(25.0) 9(75.0) 0.54 Hospitalization in the last year 1.05 0.60-1.83 0.87 0.42 Presence of wound 3.60 1.23-10.49 0.003 0.57 City 0.70 0.41-1.21 0.21 1.96 0. 71-5.43 0.13 0.49 Systemic impairment 0.17 Clinic ICU 4(40.0) 6(60.0) 1 Medical 19(51.4) 18(48.6) 0.78 0.34-1.77 Surgical 5(31.3) 11(68.8) 1.28 0.45-3.66 Yes 17(51.5) 16(48.5) No 11(36.7) 19(63.3) Yes 8(33.3) 16(66.7) No 20(51.3) 19(48.7) Yes 4(66.7) 2(33.3) No 24(42.1) 33(57.9) 0.38 3(13.0) 7(70.0) 1 13(35.1) 24(64.9) 0.85 0.30-2.42 4(25.0) 12(75.0) 1.20 0.34-4.28 9(27.3) 24(72.7) 11(36.7) 19(63.3) 0.74 0.36-1.54 6(25.0) 18(75.0) 14(35.9) 25(64.1) 0.70 0.31-1.56 3(50.0) 3(50.0) 17(29.8) 40(70.2) 1.68 0.69-4.10 0.76 Diabetes 1.40 0.79-2.50 0.24 0.42 Cardiovascular disorders 0.65 0.34-1.24 0.16 0.37 Cancer 1.583 0.83-3.01 CoNS – Coagulase-negative Staphylococcus; ICU – Intensive Care Unit; PR – Prevalence Ratio; 95%CI – 95% Confidence Interval 276 Acta Paul Enferm. 2014; 27(3):273-9. 0.39 0.37 Almeida GC, Lima NG, Santos MM, Melo MC, Lima KC Table 3. Descriptive and inferential statistics between dependent and independent quantitative variables Quantitative independent variables Dependent variables Nº days with antibiotic prior to collection Age Mean (standard deviation) p-value Median (quartile 25-quartile 75) p-value Nº days hospitalized in a hospital Median (quartile 25-quartile 75) Nº hospitalizations in the last year p-value Median (quartile 25-quartile 75) p-value Staphylococcus sp. resistance to methicillin MRSA 65.7(19.5) MSSA 61.8(23.0) 0.48 3.5(0.2-9.7) 0.02 0(0.0-3.5) 5.4(3.0-11.2) 3(2.0-5.4) 0.05 1(0.0-1.7) 1(0.0-1.0) 0.89 Staphylococcus sp S. aureus 59.5(24.1) CoNS 65.4(20.1) 0.31 0.5(0.0-3.0) 0.15 2.0(0.0-9.0) 3(2.2-5.4) 5.4(2.0-10.0) 0.20 1(0.0-1.0) 1(0.0-2.0) 0.57 CoNS – Coagulase-negative Staphylococcus; MRSA – methicillin-resistant S. aureus; MSSA – methicillin-sensitive S. aureus a Discussion Although Staphylococcus sp. is part of the resident microbiota, being mainly found in the nasal cavities,(12) they are also frequently found in hospital environment as the main agent of various infections.(13) In the present study, almost 90% of patients had Staphylococcus sp. in their nostrils, and most were CoNS rather than S. aureus. Although MRSA is more frequently studied, the mecA gene, responsible for its resistance to methicillin, can also be found in strains of methicillin-resistant coagulase-negative Staphylococcus (MR-CoNS).(7,8,14,15) The results of present study are in agreement with others(4,11,16) in which S. aureus was not the most prevalent. The nasal vestibules of about 20% of the healthy population were colonized by S. aureus,(4,5) an important pathogen that can spread throughout the community and has a high resistance potential.(14,17) However, the pathogen-host interactions are partially understood, and this is our reason for investigating this subject.(5) Advanced age, prior hospitalization, use of intravascular catheter, prior MRSA colonization, presence of wounds and/or ulcers, prolonged use of antibiotics, and severity of disease were considered risk factors for hospital MRSA. It should be stated that the bacteria must colonize a patient who has not been recently hospitalized, used antimicrobial agents, or had a catheter implanted to be considered a community MRSA.(18,19) In this sense, most patients involved in our study were admitted to the hospital for treatment of an injury, bedsore, diabetic foot, or erysipela. Additionally, most of them were subject to risk factors related to hospital admission, which favored colonization by hospital MRSA. Furthermore, there was a history of prior hospitalization in more than half of the cases in the study with MRSA and most patients had systemic impairment. Many studies have reported the presence of MRSA strains in the nasal mucosa, even at low levels,(2,4-6,10,20)associated with greater morbidity and mortality. In the present study, the prevalence of MRSA was almost 10%, a value similar to that obtained in other studies involving hospitalized patients or health professionals.(15,21) There are reports of nasal colonization of healthy individuals by MRSA (1-8%), which represent a potential risk factor for subsequent infection by S. aureus.(15,19) Although much attention has been directed to the resistance of S. aureus, CoNS should also be studied due to an increase in the resistant strains. In the present study, the level of resistance to methicillin was relatively high, with similar values for both S. aureus and CoNS. Among nursing students,(3) all samples of S. aureus isolated in their nostrils were sensitive to oxacillin, whereas 79 samples of CoNS were resistant to it; 10 of these samples were resistant to both oxacillin and cefoxitin. Similarly, almost 50% of the CoNS were resistant to methicillin among pharmacy students.(7) To verify this relationship among health workers, a study with health professionals found that more than 50% of S. epidermidis isolated from their nasal mucosae were resistant and positive for the mecA gene.(8) In this context, we found that resistance for both S. aureus and CoNS among hospitalized patients is equivalent, bringing a greater concern with cross contamination in the hospital environment by resistant strains of Staphylococcus. Acta Paul Enferm. 2014; 27(3):273-9. 277 Nasal colonization by Staphylococcus sp. in inpatients Presence of methicillin-sensitive Staphylococcus sp. was significantly associated with non-use by patients of antibiotic prior to sample collection, as well as absence of wounds on their bodies. On the other hand, methicillin-resistant Staphylococcus sp. exhibited a significant statistical difference between the number of days under antibiotic therapy prior to data collection and the resistant strains subject for more days to antimicrobial therapy. In a study with hospital patients in Madagascar, presence of S. aureus in their nostrils was significantly associated with prior use of antimicrobial agents and prior hospitalization, whereas prior use of antibiotics was significantly associated with presence of MRSA.(19) Another factor described in the literature, which is significantly associated with the presence of MRSA, is prior hospitalization of the patient.(19) In the present study this was however not evident, since hospitalization in the previous year was not significant for the presence of either resistant Staphylococcus sp. or S. aureus. Nevertheless, more than half of the patients with MRSA in the study were admitted to the hospital in the previous year. There was no significant association between Staphylococcus sp. (S. aureus or CoNS) in the nostrils and any of the independent variables of the study, whether sociodemographic or relative to the medical profile of the patient. Regarding the CoNS, a study in French Guiana(12) also did not find any association between the transport of methicillin-resistant CoNS and sociodemographic characteristics and those relative to health. Thus, the high frequency of colonization by methicillin-resistant CoNS probably depends on the overall prevalence of transport of these strains in the community and not on individual characteristics. (12) This fact is relevant since it indicates the importance of the upper air waves in the acquisition and transmission of microorganisms, as literature indicates that nasal colonization is responsible for the colonization of the cutaneous surface of the body.(6) Control measures for routine application require continued education, periodic bacteriological surveillance of those who work in the hospital environment, and application of best practices in infection control while they take care of patients. 278 Acta Paul Enferm. 2014; 27(3):273-9. Conclusion Strains of methicillin-resistant Staphylococcus sp. were found among patients in the hospital where the study was conducted. However, no significant difference was found between the S. aureus species and the CoNS group, showing the scale of the spread of methicillin resistance among different species of Staphylococcus. In this perspective, association of bacterial resistance with prior use of antibiotics for a long period, indicates that their indiscriminate use is dangerous. Collaborations Almeida GCM; Lima NGM; Santos MM; Melo MCN and Lima KC contributed to the project design, analysis, and interpretation of data, drafting the article, critical revision, and final approval of the manuscript. References 1. Queiroz GM, Silva ML, Pietro RC, Salgado HR. [Microbial multidrug resistance and therapeutic options available]. Rev Bras Clin Med. 2012;10(2):132-8. Portuguese. 2. Fortaleza CR, Melo EC, Fortaleza CM. [Nasopharyngeal colonization with methicillin-resistant Staphylococcus aureus and mortality among patients in an intensive care unit]. Rev Latinoam Enferm. 2009;17(5):677-82. Portuguese. 3. Pereira EP, Cunha ML. [Evaluation of nasal colonization for oxacillin resistant Staphylococcus spp. in nursing students]. J Bras Patol Med Lab. 2009;45(5):361-9. Portuguese. 4. Ammerlaan HS, Kluytmans JAW, Wertheim HF, Nouwen JL, Bonten MJ. Eradication of Methicillin-Resistant Staphylococcus aureus carriage: a systematic review. Clin Infect Dis. 2009;48(7):922-30. 5. Weidenmaier C, Goerke C, Wolz C. [Staphylococcus aureus determinants for nasal colonization]. Trends Microbiol. 2012;20(5):243-50. 6. Ferreira WI, Vasconcelos WS, Ferreira CM, Silva MF, Gomes JS, Alecrim MG. [Prevalence of methicillin resistant Staphylococcus aureus (MRSA) in patients treated in a general dermatology clinic in Manaus, Amazonas]. Rev Patol Trop. 2009;38(2): 83-92. Portuguese. 7. Al-Bakri AG, Al-Hadithi H, Kasabri V, Othman G, Kriegeskorte A, Becker K. The epidemiology and molecular characterization of methicillinresistant staphylococci sampled from a healthy Jordanian population. Epidemiol Infect. 2013;141(11):2384-91. 8. Pourmand MR, Abdossamadi Z, Salari MH, Hosseini M. Slime layer formation and the prevalence of mecA and aap genes in Staphylococcus epidermidis isolates. J Infect Dev Ctries. 2011;5(1):34-40. 9. Soldera J, Nedel WL, Cardoso PR, D’Azevedo PA. Bacteremia due to Staphylococcus cohnii ssp. urealyticus caused by infected pressure Almeida GC, Lima NG, Santos MM, Melo MC, Lima KC ulcer: case report and review of the literature. Sao Paulo Med J. 2013;131(1):59-61. on molecular methicillin-resistant Staphylococcus aureus Screening Tests. J Clin Microbiol. 2013;51(7):2418-20. 10. Silva EC, Samico TM, Cardoso RR, Rabelo MA, Bezerra Neto AM, Melo FL, et al. [Colonization by Staphylococcus aureus among the nursing staff of a teaching hospital in Pernambuco]. Rev Esc Enferm USP. 2012;46(1):132-7. Portuguese. 16.Scribel LV, Scribel MV, Bassani E, Barth AL, Zavascki AP. Lack of methicillin-resistant Staphylococcus aureus nasal carriage among patients at a Primary-Healthcare Unit in Porto Alegre, Brazil. Rev Inst Med Trop. 2011;53(4):197-9. 11. Instituto Brasileiro de Geografia e Estatística (IBGE). Synthesis of social indicators: an analysis of the living conditions of the population in 2012. Studies and research - demographic and socioeconomic. IBGE; 2012. 293p. Portuguese. 17. Pardo L, Vola M, Macedo-Vinas M, Machado V, Cuello D, Mollerach M, et al. Community-associated methicillin-resistant Staphylococcus aureus in children treated in Uruguay. J Infect Dev Ctries. 2013;7(1):10-6. 12. Lebeaux D, Barbier F, Angebault C, Benmahdi L, Ruppé E, Felix B, et al. Evolution of nasal carriage of methicillin-resistant coagulase negative Staphylococci in a remote population. Antimicrob Agents Chemother. 2012;56(1): 315-23. 13. Bonesso MF, Marques SA, Cunha ML. Community-acquired methicillinresistant Staphylococcus aureus (CAMRSA): molecular background, virulence, and relevance for public health. J Venomous Anim Toxins incl Trop Dis. 2011;17(4):378-86. 14. Sivaraman K, Venkataraman N, Cole AM. Staphylococcus aureus nasal carriage and its contributing factors. Future Microbiol. 2009;4(8):9991008. 15.Trouillet-Assant S, Rasigade JP, Lustig S, Lhoste Y, Valour F, Guerin C, et al. Ward-Specific Rates of Nasal Cocolonization with MethicillinSusceptible and -Resistant Staphylococcus spp. and potential impact 18.Ding Q, Li DQ, Wang PH, Chu YJ, Meng SY, Sun Q. Risk factors for infections of methicillin-resistant Staphylococci in diabetic foot patients. Zhonghua Yi Xue Za Zhi. 2012;31;92(4):228-31. 19.Rasamiravaka T, Rasoanandrasana S, Zafindraibe NJ, Alson AOR, Rasamindrakotroka A. Evaluation of methicillin-resistant Staphylococcus aureus nasal carriage in Malagasy patients. J Infect Dev Ctries. 2013;7(4):318-22. 20.Lu SY, Chang FY, Cheng CC, Lee KD, Huang YC. Methicillin-resistant Staphylococcus aureus nasal colonization among adult patients visiting emergency department in a medical center in Taiwan. PLoS ONE. 2011;6:e18620. 21. Rongpharpi SR, Hazarika NK, Kalita H. The prevalence of nasal carriage of Staphylococcus aureus among healthcare workers at a tertiary care hospital in assam with special reference to MRSA. J Clin Diagn Res. 2013;7(2):257-60. Acta Paul Enferm. 2014; 27(3):273-9. 279 Original Article Occurrence of occupational accidents involving potentially contaminated biological material among nurses Ocorrência de acidentes de trabalho com material biológico potencialmente contaminado em enfermeiros Marília Duarte Valim1 Maria Helena Palucci Marziale1 Miyeko Hayashida1 Miguel Richart-Martínez2 Keywords Accidents, occupational; Universal precautions; Security measures; Occupational health nursing; Exposure to biological agents Descritores Acidentes de trabalho; Precauções universais; Medidas de segurança; Enfermagem do trabalho; Exposição a agentes biológicos Submitted April 7, 2014 Accepted May 26, 2014 Corresponding author Marília Duarte Valim Bandeirantes Avenue, 3900, Ribeirão Preto, SP, Brazil. Zip Code: 14040-902 [email protected] DOI http://dx.doi.org/10.1590/19820194201400047 280 Acta Paul Enferm. 2014; 27(3):280-6. Abstract Objective: To investigate the occurrence and characteristics of accidents involving potentially contaminated biological material in nurses. Methods: Cross-sectional study involving 121 nurses. The research instrument was a self-applied questionnaire with sociodemographic and occupational accident-related variables. Results: Sixty-five (53.8) nurses were victims of occupational accidents involving exposure to potentially contaminated biological material. Sixty-three (52.1%) were related to piercing-cutting materials and 22 (18.2%) to exposure of the mucosa and/or non-intact skin. No statistically significant difference between the groups was found in terms of accident events and reporting (p=0.791 and p=0.427); knowledge of the immune response (p=0.379); change of piercing-cutting material collector (p=0.372) and training on standard precautions (p=0.158). A statistically significant different in the training was found (p=0.014), as nurses working at smaller establishments indicated greater desire to participate. Conclusion: Accidents are frequent among the nurses and training is positively related with adherence to standard precautions. Resumo Objetivo: Investigar ocorrência e características dos acidentes com material biológico potencialmente contaminado em enfermeiros. Métodos: Estudo transversal que incluiu 121 enfermeiros. O instrumento de pesquisa foi um questionário autoaplicável com variáveis sociodemográficas e relacionadas a acidentes de trabalho. Resultados: Em relação à ocorrência de acidente do trabalho com exposição a material biológico potencialmente contaminado entre enfermeiros, 65 (53,8%) foram vítimas. Destes, 63 (52,1%) por perfurocortantes e 22 (18,2%) por exposição à mucosa e/ou pele não íntegra. Não houve diferença estatisticamente significativa entre os grupos quanto à ocorrência e notificação do acidente (p=0,791 e p=0,427); conhecimento da resposta vacinal (p=0,379); troca de recipiente de perfurocortantes (p=0,372) e treinamento sobre precauções padrão (p=0,158). Com relação ao treinamento foi verificada diferença estatisticamente significativa (p=0,014) uma vez que enfermeiros nos estabelecimentos menores relataram maior desejo de participação. Conclusão: Os acidentes são frequentes entre os enfermeiros e o treinamento relaciona-se positivamente à adesão às precauções-padrão. Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil. Universidad de Alicante, Alicante, Spain. Conflicts of interest: no conflicts of interest to declare. 1 2 Valim MD, Marziale MH, Hayashida M, Richart-Martínez M Introduction The double goal of the standard precautions is to protect health professionals against possible occupational contamination in care delivery and to prevent healthcare-related infections.(1) In occupational health, the possibility of contamination by occupationally relevant pathogens like the HIV virus and the HBV and HCV virus can be prevented.(2) In 1996, 18 years ago, the Centers for Disease Control and Prevention (CDC) established the standard precautions, which contain the main concepts of universal precautions and isolation of body substances, based on the principle that any body fluids (except sweat) can contain infectious agents.(3) The infection by the HIV virus in the United States among professionals who did not report other than occupational risk factors was investigated in a CDC protocol entitled “Cases of Public Health Importance” (COPHI).(4) In that source, it is reported that records between 1981 and 2010 indicate that 57 North American workers were victims of seroconversion after occupational accidents involving exposure to potentially contaminated biological material, although at least 143 cases are under investigation, the most recent of which happened in 2009. Therefore, the number of professionals who caught the infection is uncertain. In addition, there is possible underreporting. In developing countries, the surveillance and control systems need to be improved and health establishments need to encourage reporting,(5,6) as there are no precise data about the number of cases of seroconversion to HIV and hepatitis B and C among health professionals in the Brazilian context. In Brazil, occupational accidents involving exposure to potentially contaminated biological material are considered a health problem of compulsory reporting and should be notified on a form standardized by the Ministry of Health in the National Disease Notification System - SINAN-NET and in sentinel networks, such as the Occupational Health Referral Centers - CEREST.(7) In a study undertaken to analyze these accidents, important gaps were appointed, showing the need to train the professionals responsible for the records.(6) Studies indicate the need for training and awareness-raising of the workers about the adherence to standard precautions(8,9), as these accidents are still frequent and can entail severe consequences for the workers’ physical and psychosocial wellbeing.(10) Adherence to standard precautions is the main strategy to protect workers against exposure to transmissible pathogens and to protect patients,(11) but adherence is below recommended levels.(8,12) A study found that training and knowledge about the theme positively influence the adherence.(13) In the same context, a study at hospitals and medical centers in Ethiopia identified that more than half of the health workers possessed inappropriate knowledge about the standard precautions and that 95.5% actually wanted to receive some kind of training.(14) Adherence to infection control and safety practices can also be influenced by the size of the establishments. Studies show that adherence to safety measures is higher in larger hospitals when compared to smaller hospitals and establishments. (5,15) One of the reasons can be the fact that smaller establishments are generally more basic and have a more limited structure and less activities of the infection control commissions.(5) It was observed that the constant presence of training, a prepared and exclusive team for infection control and patient safety, greater financial investments and participation of organizational management in these activities are positively related with better infection control practices.16,17)As the human and financial resources vary significantly among different types of health establishments, teaching hospitals tend to exert infection control practices more effectively than municipal or philanthropic hospitals, which are often smaller and receive less financial incentives.(17) The objective in this study was to investigate and compare the occurrence and characteristics of accidents involving biological material in nurses at a teaching hospital and smaller health establishments. Methods A cross-sectional study was undertaken at health establishments in two Brazilian cities between SepActa Paul Enferm. 2014; 27(3):280-6. 281 Occurrence of occupational accidents involving potentially contaminated biological material among nurses tember and December 2012, including one teaching hospital and three smaller institutions. The teaching hospital is characterized as size IV and is considered a referral center for high-quality research areas. The items assessed for the characterization as size IV are: 300 beds or more, 30 of which for the intensive care unit (ICU); more than eight surgery rooms; reference level III for urgency and emergency and ICU and four or more high-complexity sectors.(18) The smaller establishments include one philanthropic hospital, one private hospital that also offers beds to the Unified Health System (SUS) and an emergency care unit affiliated with a regional health insurance. The philanthropic institution offers 155 beds; the other hospital 78 beds, the emergency care service consists of an emergency unit and a medication room and eight beds for observation. Nurses were included with at least three months of professional experiences, who were not on holiday, medical leave or leave of absence. Professionals in exclusively administrative functions or not present at the place of work after two consecutive attempts were excluded. The sample was randomly composed of 120 nurses from the teaching hospital and the nurses working at the smaller establishments who complied with the inclusion criteria, totaling 39 professionals. It should be highlighted that, in 2011, 411 nurses worked at the teaching hospital. The final sample consisted of 121 nurses, 91 from the teaching hospital and 30 from the smaller establishments. Therefore, the response rate corresponded to 75.8% for the university hospital and 77.0% for the other establishments. The questionnaire with sociodemographic characteristics included the following variables: sex; work sector; birth date; education level; workplace and length of professional experience. The following variables were considered related to the occurrence of an occupational accident with exposure to potentially contaminated biological material: vaccination for Hepatitis B and knowledge about the anti-HBs antibody; accident reporting; practice of change of disposal container for piercing-cutting 282 Acta Paul Enferm. 2014; 27(3):280-6. material; participation and desire to participate in training about standard precautions. The responsible researchers provided the workers with the questionnaires during their work hours. As the questionnaire was self-explained, the participants were advised to complete it when they had time and to leave the completed questionnaires in a sealed box in the nursing head’s office in each sector for the researcher to collect. The box was available for approximately two weeks in each sector and, during the shift after they had received the questionnaire, the researcher contacted the nurses to know if they had handed it in. In case they had not answered it yet, the researcher used the occasion to remind them about the importance of their participation. The numerical variables are described using descriptive statistics, calculating the means, medians and standard deviations. The nominal categorical variables are described or displayed in frequency tables. Pearson’s chi-square test was applied for the categorical or dichotomous variables, such as “participation in training about SP”, “change of piercing-cutting material container” and “knowledge about anti-HBs antibody” to compare whether there was a statistically significant difference between the two groups of nurses. For the variables “accident reporting” and “desire to participate in training”, Fisher’s exact test was applied. For the variable “number of accidents involving piercing-cutting material”, the Mann-Whitney test was applied as no normal distribution was verified. The development of the study complied with Brazilian and international standards for research involving human beings. Results The participants mainly included women, between 20 and 40 years of age. The mean age at the teaching hospital was 37.4 years (SD±8.95), median 35, maximum 58 and minimum 23 years. At the smaller establishments, the mean age was 32.5 years, median 33, minimum 23 and maximum 50 years of age. The majority (51.2%) held Valim MD, Marziale MH, Hayashida M, Richart-Martínez M a specialist degree and only 8.3% a Master’s and/ or Doctoral degree, as demonstrated in table 1. Table 1. Distribution of the nurses (n=121) according to sex, age range, education and place of work Variables n(%) Gender Female Male 110(90.9) 11(9.1) Age range (years) 20 to 30 38(31.4) 31 to 40 50(41.3) 41 to 50 18(14.9) ≥ 51 12(9.9) Missing data 3(2.5) Education level Higher Specialization ongoing Specialization 34(28) 6(5) 62(51.2) Master’s ongoing 2(1.7) Master’s 8(6.6) Doctoral ongoing Doctoral 6(5) 2(1.7) Place of work Teaching hospital Emergency unit 32(26.4) Teaching hospital 59(48.8) Smaller health establishments Philanthropic hospital 16(13.2) Private hospital 7(5.8) Emergency care 7(5.8) The length of professional experience corresponded to between three months and five years for 31.4%, between six and ten years for 23.1%, between 11 and 15 years for 20.7% and 16 years or more for 24.8%. The mean length of professional experience was 10.1 years (SD 7.22). As regards the sector, 31 nurses (25.5%) were allocated to medical and surgical clinics; 29 (23.8%) belonged to adult, neonatal and/or pediatric intensive care units; 10 (8.4%) worked in emergency care; nine (7.4%) in pediatrics; eight (6.6%) belonged to the gynecology and obstetrics sector and 34 (28.3%) to the other sectors investigated: orthopedics, dermatology and immunology, psychiatrics, neurology, coronary unit, infectious diseases, outpatient clinics, hematology and liver transplantation. Concerning the occurrence of occupational accidents involving exposure to potentially contaminated biological material among nurses, 65 (53.8%) were victims. Sixty-three (52.1%) involved piercing-cutting material and (18.2%) exposure of the mucosa and/or non-intact skin. It should be highlighted that 50.5% of the nurses at the teaching hospital affirmed they had been victims of occupational accidents with piercing-cutting material, against 56.7% at the smaller establishments. The results show that 81.4% and 92.9% of the victims at the teaching hospital and smaller establishments, respectively, notified the events. Among the justifications for not reporting, two nurses indicated that they did not consider notification necessary and two that they did not consider the occupational accident they were victims of as dangerous; two did not notify due to forgetting or the stress the accident caused and one justified the delay in returning to the responsible units. The vaccination schedule for hepatitis B was complete in 97.5% of the nurses, but 46.2% of the nurses at the teaching hospital indicated not having the recommended immune response and 26.4% did not know the response. At the smaller establishments, 36.7% indicated not knowing about the presence of the anti-HBs antibody and 40.0% could not provide this important information. The data revealed that 44.0% and 53.3% of the sectors at the teaching hospital and at the smaller establishments, respectively, did not change the piercing-cutting material collector after one-third had been filled. Concerning the participation in training about standard precautions, 87.9% of the nurses at the teaching hospital and 80.0% at the smaller establishments affirmed they had participated in institutional training. Nevertheless, 96.7% of the nurses at the smaller establishments indicated the desire to participate, against 77.7% at the teaching hospital. No statistically significant difference between the groups was found regarding the accident occurrence and notification (p=0.791 and p=0.427); knowledge about the immune response (p=0,379); change of the container (p=0.372) and training about standard precautions (p=0.158). As regards the desire to participate in training, a statistically significant difference was verified (p=0.014), as nurses working at the smaller establishments indicated greater desire to participate (Table 2). Acta Paul Enferm. 2014; 27(3):280-6. 283 Occurrence of occupational accidents involving potentially contaminated biological material among nurses Table 2. Occurrence and notification of accidents involving biological material according to piercing-cutting material, immune response, container change, participation and desire to participate in training Teaching hospital n(%) Smaller establishments n(%) Yes 46(50.5) 17(56.7) No 45(49.5) 13(43.3) Yes 35(81.4) 13(92.9) No 8(18.6) 1(7.1) Variables p-value Accident with piercing-cutting material 0.791* Accident reporting 0.427** Knowledge immune response Yes 24(26.4) 7(23.3) No 42(46.2) 11(36.7) Unknown 24(26.4) 12(40.0) 1(1.0) - Yes 51(5.0) 14(46.7%) No 40(44.0) 16(53.3) Yes 80(87.9) 24(80.0) No 9(9.9) 6(20.0) Did not answer 2(2.2) - Yes 70(77.7) 29(96.7) No 21(22.3) 1(3.3) Did not answer 0.379* Change of containers 0.372* Participation in training 0.158* Desire to participate in training 0.014** *Application of Pearson’s Chi-square test **Application of Fisher’s exact test Discussion The research findings are important to compare the occurrence of occupational accidents involving exposure to potentially contaminated biological material in different establishments. No significant difference was found in the occurrence and characteristics of the occupational accidents with regard to the establishments studied. As to the training about standard precautions, no statistically significant difference was verified, despite the larger proportion of nurses who participated at the teaching hospital. Nurses from the smaller establishments demonstrated greater desire to participate in updated about the theme, with a statistically significant difference. The sociodemographic analysis results are demonstrated in other studies(19) and show that nursing is still a predominantly female profes- 284 Acta Paul Enferm. 2014; 27(3):280-6. sion, with ages below 40 years. Most of the nurses (52.40%) had some kind of specialization, which is possibly associated with the teaching hospital, which needs to attend to different highly complex specialties. As regards the occurrence of occupational accidents with piercing-cutting material, the same proportion was found in other studies,(19) which may be related with the number of invasive procedures nurses perform, such as venipuncture, serum therapy, collection of laboratory tests, capillary glucose, among others.(20) What non-reporting is concerned, the justifications that they consider reporting unnecessary or attribute a low level of danger to the accident are in accordance with other findings.(20) It is known that the risk of catching the HCV virus after occupational exposure ranges between 1.8% and 0.3 to 0.5% for the HIV virus in cases of percutaneous exposure. As for the hepatitis B virus, these percentages range between 6 and 30%.(21) Hence, the need to report the accident and monitor the victim for six months after the exposure is highlighted, including serology tests and correct completion of the case evolution in SINAN NET.(7) The vaccination schedule for hepatitis B and the lack of knowledge about the antibody is also in line with the research. In one study, it is indicated that, although 99.8% of the victims indicated a complete schedule for hepatitis B, only 40% referred the presence of the anti-HBs antibody, while 16.1% indicated no response, 18.5% that they did not take the test and 20% did not complete this important information.(6) The results about the change of the piercing-cutting material collector differ from guidelines for health establishments and encourage the proposal of prevention and intervention measures.(22) As regards the participation in training about standard precautions, the desire to participate in both groups of nurses was considerable, arousing reflections about the impact of the previously proposed training. It should be highlighted that the occurrence of accidents involving biological material in the research groups drive towards the formulation and implementation of prevention and control measures, as more than half of the nurses reported having suffered at least Valim MD, Marziale MH, Hayashida M, Richart-Martínez M one type of exposure to potentially contaminated biological material in their professional career. Study variables related to the occurrence of accidents, such as the presence of the anti-HBs antibody and the change of collectors lead to the conclusion that important safety measures are not being practiced. In a study involving 1444 Chinese nurses, it was revealed that only half had received training about standard precautions, and 98.2% expressed the desire to receive training.(5) In a study developed in Jamaica, nurses and physicians wanted to participate in training, as well as qualification related to the control of healthcare related infections.(8) Professional education based on the principles and reasons for the monitoring of safety practices are critical elements of standard precautions, as they facilitate the correct decision process and promote adherence. (23) As studies reveal that training is directly related with nurses’ adherence to standard precautions,(5,9) continuous training of the workers is suggested with a view to the adherence to safety measures. Simply offering training is not sufficient though, as studies evidence that knowledge about the standard precautions remained below desirable levels, even after training, which reinforces the need for evidence-based training contents and forms.(24) Even after training, the study reveals that only 47% of the workers considered the risk of body fluid droplets in the eye mucosa a possible source of contamination, only 63% understood the basic concept of standard precautions and only 53.24% perceived the need to use a mask in the physical examination of patients with respiratory symptoms. A multimodal strategy by Brazilian health agencies to achieve adherence to hand washing indicates that a set of actions is needed to overcome different behavioral obstacles and barriers. The institutions need to guarantee the infrastructure needed to permit the correct practice of the procedure and provide training and continuing education with assessment and feedback of the data related to the workers’ practice, perception and knowledge about the theme.(25) The same source indicates that, to achieve adherence to the standard precautions, an environment needs to be created that facilitates the professionals’ sensitization to patient safety, so as to include active participation at the institutional and individual level. A review of factors that influence adherence indicates that variables like the organizational safety climate, perceived obstacles, professional degree, care delivery to a smaller number of patients, risk personality and self-efficacy should not be ignored.(26) Conclusion Accidents involving exposure to biological material are frequent. Although the professionals reported having received training about standard precautions, there was a great desire for reinforcement on the theme. Collaborations Valim MD participated in the conception of the project, analysis and interpretation of the data, writing of the article and relevant critical review of the intellectual content. Marziale MHP participated in the conception of the project, analysis and interpretation of the data, writing of the article, relevant critical review of the intellectual content and approval of the final version for publication. Richart-Martinez and Hayashida M participated in the analysis and interpretation of the data and relevant critical review of the intellectual content. References 1. Siegel JD, Rhinehart E, Jackson M, Chiarello L. Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings [Internet]. 2007 [cited 2012 Jan 01]. Available from: http:// www.cdc.gov/ncidod/dhqp/pdf/guidelines/isolation2007.pdf. 2. Kuhar DT, Henderson DK, Struble KA, Heneine W, Thomas V, Cheever LW, Gomaa A, Panlilio AL; US Public Health Service Working Group. Update US Public Health Service guidelines for the management of occupational exposures to human immonudeficiency virus and recommendations for postexposures prophylaxis. Infect Control Hosp Epidemiol. 2013;34 (9):875-92. 3. Garner JS. Guideline for isolation precautions in hospitals. The Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1996;17(1):53-80. 4. Centers for Disease Control and Prevention (CDC). Department of Health and Human Services - USA. Surveillance of Occupationally Acquired HIV/AIDS in Healthcare Personnel, as of December 2010 [Internet]. 2010 [cited 2014 Feb 02]. Available from: http://www.cdc. gov/HAI/organisms/hiv/Surveillance-Occupationally-AcquiredHIV-AIDS.html. 5. Luo Y, He GP, Zhou JW, Luo Y. Factors impacting compliance with standard precautions in nursing, China. Int J Infect Dis. 2010;14(12):e1106-14. Acta Paul Enferm. 2014; 27(3):280-6. 285 Occurrence of occupational accidents involving potentially contaminated biological material among nurses 6. Valim MD, Marziale MHP. Evaluating occupational exposure to biological material in health services. Texto & Contexto Enferm. 2011; 20(Spec):138-46. 17. Fukuda H, Imanaka Y, Hirose M, Hayashida K. Factors associated with system-level activities for patient safety and infection control. Health Policy. 2009 89(1): 26–36. 7. Ministério da Saúde (BR). Portaria nº 777/GM de 28 de abril de 2004: dispõe sobre os procedimentos técnicos para a notificação compulsória de agravos à saúde do trabalhador em redes de serviço sentinela específica, no Sistema Único de Saúde. Brasília (DF): MS; 2004 [citado 2010 Fev 2]. Disponível em: http://dtr2001.saude.gov. br/sas/PORTARIAS/Port2004/GM/GM-777.htm. 18. Brasil. Ministério da Saúde. Portaria nº 2224 de 5 de dezembro de 2002. Dispõe sobre o sistema de classificação hospitalar do Sistema Único de Saúde. In: Diário Oficial da República Federativa do Brasil. Brasília (DF): MS; 2002 [citado 2014 Fev 2]. Disponível em: http://www.jusbrasil.com. br/diarios/767477/dou-secao-1-06-12-2002-pg-37/pdfView. 8. Foster TM, Lee MG, Mcgaw CD & Frankson MA. Knowledge and practice of occupational infection control among healthcare workers in Jamaica. West Indian Med J. 2010;59(2):147–52. 9. Li L, Chunqing L, Zunyou W, Jihui G, Jia M & Zhihua Y. HIV-related avoidance and universal precaution in medical settings: opportunities to intervene. Health Ser Res. 2011;46(2):617-31. 20. Pimenta FR, Ferreira MD, Gir E, Hayashida M, Canini SR. Atendimento e seguimento clínico especializado de profissionais de enfermagem acidentados com material biológico. Rev Esc Enferm USP. 2013; 47(1): 98-204. 10.Araújo TM, Barros LM, Caetano JA, Araújo FN, Ferreira Junior FC, Feitosa AC. Acidente ocupacional e contaminação pelo HIV: sentimentos vivenciados pelos profissionais de enfermagem. Rev Pesqui Cuid Fundam . 2012;4(4):2972-9. 21.Centers for Disease Control and Prevention (CDC). Workbook for designing, implementing and evaluating a sharp injury prevention program. [Internet]. 2008 [cited 2014 Fev 2]. Available from: www. 11. World Health Organization. Practical guidelines for infection control in health care facilities [Internet]. Manila: WPRO Regional Publication; 2007 [cited 2014 Jan 20]. Available from: http:// whqlibdoc.who.int/ publications/2009/9789241597906_eng.pdf. 22. Brasil. Ministério do Trabalho e Emprego. Riscos biológicos: guia técnico os riscos biológicos no âmbito da NR 32. Brasília (DF): MTE; 2008. 12.Efstathiou G, Papastravou E, Raftopoulos V, Merkouris A. Compliance of Cypriot nurses with standard precautions to avoid exposure to pathogens. Nurs Health Sci. 2011;13(1):53-9. cdc.gov/sharpssafety. 23.Centers For Disease Control And Prevention (CDC). National Center for Emerging and Zoonotic Infectious Diseases. Infection Prevention Checklist for Outpatient Settings: Minimum Expectations for Safe Care. [Internet]. 2011 [cited 2014 14 Fev]. Available from: http://www.cdc.gov/HAI/ settings/outpatient/checklist/outpatient-care-checklist.html. 13. Askarian M, Mclaws ML, Meylan M. Knowledge, attitude, and practices related to standard precautions of surgeons and physicians in universityaffiliated hospitals of Shiraz, Iran. Int J Infect Dis. 2007;11(1):213-9. 24.Sax H, Perneger T, Hogonnet S, Herrault P, Chraiti MN, Pittet D. Knowledge of standard and isolation precaution in a large teaching hospital. Infec Control Hosp Epidemiol. 2005;26 (3):298-304. 14. Reda AA, Vandeweerd JM, Syre TR, Egata G. HIV/AIDS and exposure of healhcare workers to body fluids in Ethiopia: attitudes toward universal precautions. J Hosp Infect. 2009;71(2):163-9. 25.Brasil. Ministério da Saúde (BR). Anexo 1: Protocolo para a prática de higiene das mãos em serviços de saúde. Brasília (DF): MS; 2004 [citado 2014 Jan 13]. Disponível em: http://www.sbpc.org.br/ upload/conteudo/protocolo_higiene_maos_09jul2013.pdf. 15. Osborne S. Influences on compliance with standard precautions among operating room nurses. Am J Infect Control. 2003;31(7):415-23. 16. Fukuda H, Imanaka Y, Hayashida K. Cost of hospital-wide activities to improve patient safety and infection control: a multi-centre study in Japan. Health Policy. 2008;87(1):100-11. 286 19. Gomes AC, Agy LL, Malaguti SE, Canini SR, Cruz ED, Gir E. Acidentes ocupacionais com material biológico e equipe de enfermagem em um hospital-escola. Rev Enferm UERJ. 2009;17(2): 220-3. Acta Paul Enferm. 2014; 27(3):280-6. 26.Valim MD, Marziale MH, Richart-Martínez M, Sanjuan-Quiles A. Instruments for evaluating compliance with infection control practices and factors that affect it: an integrative review. J Clin Nurs. 2013;22 (17):1-18. Original Article Changes in Quality of Life after kidney transplantation and related factors Mudanças na qualidade de vida após transplante renal e fatores relacionados Ana Elza Oliveira de Mendonça1 Gilson de Vasconcelos Torres1 Marina de Góes Salvetti1 Joao Carlos Alchieri1 Isabelle Katherinne Fernandes Costa1 Keywords Perioperative nursing; Nursing research; Renal transplantation; Quality of life; Socioeconomic factors Descritores Enfermagem perioperatória; Pesquisa em enfermagem; Transplante de rim; Qualidade de vida; Fatores socioeconômicos Submitted April 17, 2014 Accepted May 26, 2014 Corresponding author Gilson de Vasconcelos Torres Senador Salgado Filho Avenue, 3000, Natal, RN, Brazil. Zip Code: 59078-970 [email protected] DOI http://dx.doi.org/10.1590/19820194201400048 Abstract Objective: To identify changes on quality of life after the effectiveness of kidney transplantation and verify the influence of sociodemographic factors on quality of life. Methods: This is a descriptive study with study with longitudinal design. Data were collected in a private place, using the World Health Organization Quality of Life (WHOQOL-bref) validated and culturally adapted to Brazilian Portuguese by WHOQOL-Group. Results: aged up to 35 years (50.8%), mean age 38.9 years (SD=12.9), married (60.3%), with children (51.8%). The sociodemographic factors did not influence these patients’ perception of quality of life. The QoL improved significantly in all domains. The greatest change was observed in the general QoL, Physical Domain and Social Relationship Domain. The domain that showed less variation after transplantation was the Environment Domain. Conclusion: This study examined the impact of the effectiveness of kidney transplantation on quality of life quality of life of chronic disease patients. The results indicated that transplantation had a positive impact and changed the perception of these patients. Resumo Objetivo: Identificar as mudanças na qualidade de vida após a efetivação do transplante renal e verificar a influência dos fatores sociodemográficos na percepção da qualidade de vida. Métodos: Trata-se de estudo descritivo com desenho longitudinal. Os dados foram coletados em local privado utilizando a versão abreviada do instrumento World Health Organization Quality of Life (WHOQOL-bref), adaptado e validado para língua Portuguesa por meio do Grupo WHOQOL. Resultados: Observou-se neste estudo o predomínio de pacientes adultos jovens com idade até 35 anos (50,8%) e idade média de 38,9 anos (DP=12,9). Os fatores sociodemográficos não influenciaram a percepção de qualidade de vida dos pacientes. A qualidade de vida melhorou significativamente em todos os domínios. As maiores mudanças foram observadas na qualidade de vida geral, domínio físico e domínio relações sociais. O domínio que demonstrou a menor variação após o transplante foi o domínio meio ambiente. Conclusão: Este estudo avaliou o impacto da efetivação do transplante renal na qualidade de vida de pacientes com doença renal crônica. Os resultados indicaram que o transplante teve impacto positivo na percepção de Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil. Conflicts of interest: there are no conflicts of interest to declare. 1 Acta Paul Enferm. 2014; 27(3):287-92. 287 Changes in Quality of Life after kidney transplantation and related factors Introduction The technological and scientific advances in transplantation have enabled thousands of procedures that benefit organ and tissue recipients worldwide. Transplantation benefits patients who need solid organs, tissue and cells by means of the development and improvement of surgical techniques, inputs, equipment and immunosuppressive drugs needed to this therapy.(1) The number of kidney transplant performed increased significantly, as the number of candidates.(2) In certain situations these procedures are configured as the only resource for sustaining life.(1) However, this treatment option is not always available for those who are waiting for an organ transplantation because it requires a donation.(2-4) According to the Brazilian National Transplant Registry, in June 2013 there were 22,187 patients registered on the waiting list for solid organ transplantation of these, 19,913 (89.75%) were waiting for a kidney.(5) Kidney transplantation requires compatibility between tissues obtained for the Human Leukocyte Antigen typing (HLA). While waiting for a donor, the chronic renal disease patients have other forms of Renal Replacement Therapy (RRT) allow the maintenance of their life and also justify the increasing number of patients registered on the waiting list for a kidney transplantation.(3,4) Renal Insufficiency (RI) and the complexity of their treatment constitute a serious public health problem worldwide, with social and financial burden resulting from increasing rates of young patients with renal function failure.(6) Thus, measurement of patients’ Quality of Life (QoL) after kidney transplantation, is a relevant topic for many individuals who are on dialysis in Brazil and receive care in one of the 696 dialysis centers registered in the Nephrology Brazilian Society (NBS).(7) Renal transplantation is the best therapeutic option for patients with chronic kidney disease. The surgical procedure is relatively simple, and after the transplantation important actions are necessary such as the use of immunosuppressive drugs and the outpatient follow-up.(8) Therefore, for these patients the clinical management, the evaluation of treatment results, and impacts on QoL are important issues. 288 Acta Paul Enferm. 2014; 27(3):287-92. The aim of this study was to identify changes on quality of life after effectiveness of kidney transplantation and verify the influence of sociodemographic factors on quality of life. Methods The study population consisted of all chronic renal failure patients receiving outpatient treatment at a referral center for kidney transplant in northeastern of Brazil. A total of 63 patients aged over 18 years were included. Data were collected in two steps in order to assess the perception of kidney recipients before and after transplantation. In the first step transplant candidates enrolled on the waiting list were interviewed, in the second stage, interview kidney transplantation, respecting the minimum interval of three months that was the necessary time for patient recovery and return to his/her daily life activities. All patients were informed about the objectives of the study and those who agreed to participate signed the consent form. This study was a descriptive study with longitudinal design from May 2010 to May 2013 that included a population of chronic kidney disease patients receiving outpatient treatment. The study was the only public hospital that performs kidney transplantation and provides specialized care for this population. Data were collected in a private place, using the World Health Organization Quality of Life WHOQOL-bref, validated and culturally adapted to Brazilian Portuguese by WHOQOL-Group.(9) This instrument consists of 26 closed questions t assess perceptions of QoL two general questions about health and QoL related to physical, psychological, social relationships and environment domains.(10) Responded items evaluated are distributed on 5-point Likert scale ranging from 1 to 5, with higher scores indicating better QoL. The sum of the scores obtained in each domain varies from 4 to 20. This instrument is easy to understand and its reliability was tested in patients with renal disease and it achieved a Cronbach Alpha index of 0.88, so that confirming its applicability in this group of patients.(11) Data were organized by using an electronic spreadsheet (Microsoft Office Excel®) and then Mendonça AE, Torres GV, Salvetti MG, Alchieri JC, Costa IK imported into the SPSS (version 17.0) where they categorized, processed and analyzed using descriptive and univariate statistics. Analysis of variance (ANOVA) one-way, t-test and Mann-Whitney test were performed. The level of significance was set at p< 0.05. Development of this study followed national and international ethical and legal aspects of research in human. Table 1. Associations between sociodemographic variables and quality of life pre- and post- kidney transplantation General QoL Sociodemographic Variables n(%) Pre-transplantation Pos-transplantation p-value Mann Whitney test Gender Male Female 39(61.9) 24(38.1) 0.920 0.769 32(50.8) 31(49.2) 0.692 0.066 25(39.7) 38(60.3) 0.470 0.446 32(51.8) 31(49.2) 0.195 0.494 38(60.3) 25(39.7) 0.989 0.257 31(49.2) 32(50.8) 0.776 0.717 49(77.8) 14(22.2) 0.693 0.264 Age < 35 years > 35 years Marital status Single Married Results In total, 63 patients participated in the study. The sociodemographic profile of respondents revealed a male predominance (61.9%) with mean age of 38.9 years (SD=12.9), married (60.3%), with children (51.8%). Most participants had up to 8 years of formal education and were not (90.4%) at the time of the study period. Hemodialysis was the most used (96.8%) in this group of patients and the average waiting list time for transplantation was 1.9 years (Table 1). The analysis of sociodemographic factors related to overall QoL before and after transplantation showed that these factors (gender, age, marital status, children, formal education, time on dialysis and on waiting list) did not influence these patients’ perception of quality of life. For data analysis, the mean domain scores and standard deviation (SD), were calculated in the two steps (before and after transplantation)for comparison purposes. The analysis of the scores showed that QoL improved significantly in all domains. The greatest change was observed in the general QoL questions that assessed overall satisfaction with QoL and health satisfaction. The domain that showed less variation after transplantation was the Environment Domain (Table 2). Although the Student-t test showed significant difference comparing the median scores in all domains of QoL, we observed a significant variance in General QoL (p=0.038), Physical Domain (p=0.032) and Social Relationship Domain (p=0.035), which reinforces these aspects of QoL improvement after renal transplantation. Children Yes No Formal Education < 08 years > 08 years RRT* < 05 years > 05 years Waiting list time < 2 years > 2 years * Renal Replacement Therapy Table 2. Quality of Life scores before and after kidney transplantation General Questions and Domains WHOQOL-BREF** Median Score (SD) Before Transplant After Transplant p-value t-Test ANOVA 8.57(2.01) 17.65(1.78) * <0.001 0.038* Physical domain 9.94(2.10) 17.41(1.78) <0.001* 0.032* Phychological domain 12.71(1.90) 17.70(1.66) <0.001* 0.064 Social Relation domain 12.70(2.95) 17.27(1.83) <0.001* 0.035* Environmental domain 11.98(2.14) 14.39(2.24) <0.001* 0.694 General QoL *p<0.05; **WHOQOL-BREF= World Health Organization Quality of Life Bref Discussion In this study a predominance of young adult patients aged up to 35 years (50.8%) and the mean patient age was 38.9 years (SD=12.9). This result revealed a worrying statistic because of the early development of kidney disease and its rapid progression in economically active young individuals. Differently of our study findings, a research that evaluated 107 chronic renal disease patients reported slightly higher age, the mean patient age 51.1 years.(12) Acta Paul Enferm. 2014; 27(3):287-92. 289 Changes in Quality of Life after kidney transplantation and related factors In this study there was predominance of participants married (60.3%), with children (51.8%). Similar results were found in study involving with renal disease patients more than a half of were married or liv in a stable relationship (67.7%) and as well as most of them had children (81.2%).(13,14) The most frequent education level of respondents was less than 8 years of formal education (60.3%). Different results were observed in another study including hemodialysis patients in the southeastern region of Brazil in which great part of respondents (48.6%) had completed high school.(12) The difference in education level observed in this study reflects the social inequalities and the levels human development found across Brazil. Regarding occupational status, 90.4% of participants were not working during the study period. Researches conducted with patients undergoing chronic renal dialysis showed similar results with regard to occupational status (80.0% of patients were retire and only 6.7% were working).(13,15,16) In another study, only 9.3% of respondents reported some work activity, being identified as the main reason for not working the difficult to found a balance between the time required for hemodialysis.(12) A study that compared the quality of life of kidney patients on dialysis and after transplantation found that approximately 80% of those undergoing kidney transplantation are able to return to their professional activities after three months of transplantation, while the index for patients who remained in dialysis treatment was less than 30%.(8) The arrangements for replacement therapies of renal function are divided into dialysis and renal transplantation. The dialysis can be obtained by filtration of blood in the extracorporeal circuit that is called hemodialysis (HD) or with the lining of the abdominal cavity called peritoneal dialysis. Kidney transplantation is the modality that was recently made available to patients with chronic kidney diseases, the replacement of renal function by implantation of a healthy kidney.(17) In Brazil there are about 100,000 patients on dialysis and HD is the most widely used treatment to replace the renal function.(7) The high 290 Acta Paul Enferm. 2014; 27(3):287-92. prevalence of HD was confirmed in our study, participants (96.8%) was undergoing hemodialysis three times per week, while only 3.2% underwent peritoneal dialysis. Hemodialysis partially replaces renal function and, for this reason patients enrolled in waiting list for kidney transplant can wait many years, since the treatment keeps the nitrogenous compounds at levels compatible with healthy individuals and it removes excess fluid from the bloodstream.(4,18) Most patients remained five years or more in dialysis (50.8%). Divergent results were found in another study that reported a time interval from 1 to 5 years in the most dialysis.(19) Given these findings, we highlight the need for early referral of patients who start dialysis to be registered in waiting list for kidney transplantation, especially because longterm dialysis may influence negatively the identification of a suitable donor and survival time of the transplanted organ.(8) The perception of overall QoL of patients before and after transplantation was not influenced by sociodemographic factors, confirming a result that corroborates other study that correlated sociodemographic factors and QoL after renal transplantation.(20) The comparison between the mean scores of QoL domains before and after effectiveness of transplant showed significant improvement in general QoL and in all evaluated domains, positive impact of renal transplantation on patients’ perception. This improvement was more significant in general QoL, physical health domain and social relationships domain. Similar results were observed in study that compared kidney transplant recipients and wait listed patients.(21) Study that assessed health-related QoL issues in 262 renal transplant recipients showed that the physical component was influenced by the presence hypertension and diabetes, factors such as levels of creatinine and hematocrit, that improve after transplantation.(22) The Social elation domain assesses the patient’ degree of satisfaction relation to the time spend with family and friends and also the support given by them. This domain showed a sig- Mendonça AE, Torres GV, Salvetti MG, Alchieri JC, Costa IK nificant increase in the average score after transplantation. A study that evaluated patients on hemodialysis indicated that the domain of social relations was considered very relevant for kidney patients because of needs and dependence of support the course of the disease.(2,4) Another study showed that social relationships influence the perception of QoL and it affects health, welfare and susceptibility of the patient to deal with the disease process, for this reason, the social relationship is configured as a space for exchanging experiences, potential development and social protection.(23) The psychological domain reflects the results of transplantation as the fears and emotions of patients, demonstrating perceptions of coping strategies in situations of distress.(24) The emotional aspects should be considered as important indicators of health and QoL in chronic kidney diseases patients, since the changes in lifestyle imposed by the disease, treatment and progression of symptoms might limit patients’ daily activities and also cause negative effects on their perception of QoL.(22,24-26) Other studies found that psychological factors tend to improve after transplantation.(21,25) Although the environment domain has presented the lowest scores compared to other QoL domains, it showed significant difference before and after transplantation indicating improvements in this aspect. This result can be explained in part by the safety and property conditions of participants that usually do not change after transplantation effectiveness. Study that evaluated the QoL of 120 renal patients using the WHOQOL-BREF, obtained similar results in relation to the environment Domain with lower scores when compared with other areas.(9) This results indicated that patients undergone renal transplantation had improvements in all dimensions of quality of life improvement evaluated by WHOQOL-BREF compared to before transplantation as confirmed by other studies.(3,8,25) This study contributes to the research literature on QoL chronic renal diseases patients submitted to kidney transplantation. Recent research that examined the influence of health-related QoL issues in patients undergoing renal transplantation reported that QoL scores were able to predict mortality and graft failure independently of sociodemographic and clinical risk factors of the patients, therefore, indicating the importance of QoL evaluation in this group of patients.(27) Conclusion This study examined the impact of effectiveness of kidney transplantation on QoL chronic renal disease patients. The results indicated that transplantation had a positive impact, changing the perception of QoL in patients. All domains of QoL showed improvement after transplantation, especially those related to the general QoL perception. Sociodemographic factors did not influence our group of patients so that indicating that transplantation was the main reason that explains changes in quality of life. 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Souza AM, Dutra LM. Life`s quality of the patients submitted to renal transplant in the Hospital Regional da Asa Norte. Com Ciências Saúde. 2013;24(1):9-20. 21.Kovacs AZ, Molnar MZ, Szeifert L, Ambrus C, Molnar-Varga M, Szentkiralyi, Mucsi I, Novak M. Sleep disorders, depressive symptoms and health-related quality of life—a cross-sectional comparison between kidney transplant recipients and waitlisted patients on maintenance dialysis. Nephrol Dial Transplant 2011; 26:1058–1065. 11.Mendonça AE, Farias GM, Lima CM. Validation of World Health Organization Instrument to assess quality of life bref on renal patients. Fiep Bulletin. 2009;79 (Spec Ed):236-38. 22. Bohlke M, Marini SS, Rocha M, Terhorst L, Gomes RH, Barcellos FC, et al. Factors associated with health-related quality of life after successful kidney transplantation: a population-based study. Qual Life Res. 2009;18(9):1185-93. 12. Kusumota L, Marques S, Haas VJ, Aparecida R, Rodrigues P. Adultos e idosos em hemodiálise: avaliação da qualidade de vida relacionada à saúde. Acta Paul Enferm. 2008; 21(N Spec):152-9. 23.Valcanti CC, Chaves EC, Mesquita AC, Nogueira DA, Carvalho EC. Religious/spiritual coping in people with chronic kidney disease undergoing hemodialysis. Rev Esc Enferm USP. 2012;46(4):838-845. 13.Bertolin DC, Pace AE, Kusumota L, Haas V. An association between forms of coping and the socio-demographic variables of people on chronic hemodialysis. Rev Esc Enferm USP. 2011; 45(5):1070-6. 24.Davison SN, Jhangri GS. Existential and supportive care needs among patients with chronic kidney disease. J Pain Symptom Manag. 2010;40(6):838-43. 14. Kirchner RM, Löbler LL, Machado RF, Stumm EM. Characterization of patients with chronic renal insufficiency in hemodialysis. Rev Enferm UFPE. 2011;5(2):199-204. 25. Joshi SA, Almeida N, Almeida A. Assessment of the perceived quality of life of successful kidney transplant recipients and their donors pre- and post-transplantation. Transplant Proc. 2013;45(4):1435-37. 15. Teo BW, Ma V, Xu H, Li J, Lee EJ. Profile of hospitalization and death in the first year after diagnosis of end-stage renal disease in a multiethnic Asian population. Ann Acad Med Singapore. 2010; 39(2):79-87. 26.Zalai D, Szeifert L, Novak M. Psychological distress and depression in patients with chronic kidney disease. Semin Dial. 2012;25(4):428–38. 16.Cavalcante ES, Silva RA, Mendonça AE, Costa MM, Miranda FA. Evaluation of the stress level of chronic kidney disease patients undergoing hemodialysis treatment. Rev Enferm UFPE. 2013;7(5):1264-70. 27.Griva K, Davenport A, Newman SP. Health-related quality of life and long-term survival and graft failure in kidney transplantation: a 12-year follow-up study. Transplantation. 2013;95(5):740-9. Acta Paul Enferm. 2014; 27(3):287-92.

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