Integralidade na prática assistencial da equipe de enfermagem: a relação da escuta na interação usuário e profissional no município de Paranavaí-PR

O presente trabalho tem como objetivo observar a atuação da equipe de enfermagem na atenção básica, buscando caracterizar como se dão as interações com o usuário, e priorizando a escuta como requisito da integralidade. Para que os profissionais de saúde percebam, identifiquem o sofrimento do usuário, torna-se necessário uma interação maior entre eles, ou seja, um diálogo. Para o exercício de um bom diálogo, faz-se necessário uma escuta atenta, buscando-se detalhes que podem estar ocultos nas falas, além do acolhimento e o vínculo, que são atributos responsáveis pela prática da assistência integral. A redução do sujeito a objeto tem sido a realidade das unidades básicas de saúde, lembrando que os usuários que procuram os serviços de saúde possuem uma vida fora dali, com estilos variados. O modo de falar, os cuidados prestados variam conforme a rotina de cada um. A pesquisa teve como suporte teórico a integralidade como exercício de boas práticas e produção de cuidado, enfatizando-se a escuta. Trata-se de um estudo de caráter qualitativo com abordagem etnográfica, que permite ao pesquisador fazer uma leitura detalhada da realidade. Os dados foram coletados através da observação participante e acompanhamento das atividades realizadas pela equipe de enfermagem de duas unidades básicas do município de Paranavaí-PR, e os achados foram devidamente registrados em diário de campo. Após as observações, os profissionais foram entrevistados. Participaram como sujeitos da pesquisa sete técnicos de enfermagem e um profissional administrativo. O material foi submetido à técnica de análise de conteúdo. A análise compreendeu as seguintes etapas: pré-análise, que se refere à leitura inicial de todo o conteúdo e organização dos dados, e análise, que compreende categorização e tratamento do material. Foram identificados pontos críticos na assistência durante a observação, como a falta do acolhimento, desorganização do serviço, a falta do exercício da escuta e o trabalho mecanizado. Nas entrevistas, foi possível desenvolver categorias com os relatos coletados, destacando-se a sensibilidade ao paciente, procura do melhor, falta de tempo e sentido da escuta. Conclui-se que a integralidade ainda é uma utopia na realidade dos serviços de saúde, e que a escuta é raramente utilizada e seu sentido tão pouco conhecido. A desorganização do serviço de saúde nas unidades básicas e o aparente conformismo dos profissionais frente a suas atividades são fatores predisponentes ao não-exercício da escuta, dificultando ainda mais a prática da integralidade. Considera-se fundamental a reflexão, por parte dos profissionais, e solução dos problemas encontrados, através de conscientização e sensibilização, modificando a assistência através de reorganizações do trabalho.

Significado da ética e bioética ao cuidar da criança e sua família no contexto ambulatorial: perspectiva do enfermeiro

O estudo propõe refletir e repensar acerca da adoção de postura profissional apoiada na ética e bioética para o cuidar do ser humano e, em especial, a criança e sua família no contexto ambulatorial. Nesta perspectiva, o cuidado de enfermagem pediátrica deve ter como alicerce um agir que considera as limitações reconhecendo as etapas do desenvolvimento e crescimento da criança, bem como o respeito à dignidade humana, sem infringir os princípios éticos e bioéticos. Nesse sentido, o objeto de estudo é a ética e a bioética no cuidar do enfermeiro a uma criança e sua família no contexto ambulatorial. Os objetivos são: Descrever como o enfermeiro relaciona os aspectos éticos e bioéticos ao cuidar da criança e sua família no contexto ambulatorial e discutir o cuidado do enfermeiro à criança e sua família no contexto ambulatorial à luz dos aspectos éticos e bioéticos. Trata-se se de um estudo descritivo, exploratório com abordagem qualitativa. O cenário para sua realização foi o ambulatório de um hospital pediátrico da rede municipal de saúde e um ambulatório de um hospital universitário, ambos situados na cidade do Rio de Janeiro, com a participação de 13 enfermeiros. Para a interpretação do material empírico foi utilizada a análise de conteúdo de Bardin na modalidade temática e interpretada à luz dos aspectos éticos e bioéticos. Como resultados emergiram duas categorias: Aspectos Éticos e Bioéticos que norteiam o cuidado à criança e sua família e A inserção dos aspectos éticos e bioéticos na prática assistencial do enfermeiro. No que se refere aos aspectos éticos e bioéticos, os enfermeiros, ao cuidarem da criança e sua família no contexto ambulatorial, procuram respeitar a individualidade, a privacidade, o sigilo e as decisões da família no tratamento da criança. Pautam-se nas legislações vigentes como o código de ética, o qual tem como princípios fundamentais: os direitos, as responsabilidades, os deveres e proibições pertinentes à conduta ética dos profissionais de enfermagem. Quanto à inserção dos aspectos éticos e bioéticos, os enfermeiros avaliam, identificam e reconhecem as diferentes situações das crianças no momento em que chegam ao ambulatório, priorizando o atendimento com classificação de risco. Nesse sentido, ao acolher a criança e sua família, utilizam como estratégia a comunicação verbal e não verbal, além da importância de ouvir/escutar a criança durante o cuidado. O estudo aponta para a importância da atuação do enfermeiro no cuidado à criança e sua família no contexto ambulatorial pautada não apenas na legislação vigente, que respalda a conduta ética profissional, mas, sobretudo, na valorização e no reconhecimento da inserção dos princípios bioéticos como: a autonomia, a beneficência, a não maleficência e a justiça na perspectiva da inclusão do ser humano como um cidadão de direitos. Desse modo, a assistência integral e individualizada, centrada na criança e sua família serão realizadas visando à garantia de seus direitos como cidadãos que devem ser contemplados em todo o processo de cuidar.

Moving to manage: A mixed methods study of later life relocation into supported housing.

This study describes relocation experiences of older people moving to supported housing in Scotland focusing on the nature of support. Using mixed methods, Phase one involved a Scottish cross-sectional survey of all people aged 65 and over moving into Coburg (Scotland) Housing Association supported accommodation during the first six months of 2008. A total of 122 respondents were included in the survey (59% response rate). People moved locally at advanced ages with moderate disability levels to achieve more manageable housing and support, suggesting ‘assistance migration’. Expectations were high, with many seeing it as a new start in life and generally positive views of moving were reported. In Phase two, five in-depth multiple-perspective longitudinal case studies were conducted to explore the experience of relocation into supported housing. In each case an older person, primary carer and the housing manager - all women – were interviewed over six months following relocation. Analysis was undertaken using a thematic framework approach (Ritchie et al., 2003). Findings suggested older women acted with agency to adapt to their new lives; recreating ‘normality’ through organising space and routines. It is argued that returning to normality formed the overarching objective of the older women as they sought to feel ‘in place’. Responsibilities for meeting assistance needs were often implicit, contested and shifting, leading to fragile, uncertain and transitory arrangements. Drawing on recent advances in developmental psychology it is argued ‘longings’ of older people, and others, to achieve an optimal life can relate and motivate towards actions such as relocation. Yet, personal ‘longings’ can be prioritised differently and may result in disputes over goal setting and ways needs are met. Further, utopian ideals must be reconciled with the reality of daily life. Policy and practitioners could adopt broader, dignity based objectives to assist older people to identify ways of aiding such reconciliation.

Self-neglect: development and evaluation of a self-neglect (SN-37) measurement instrument

Aim: To develop and evaluate the psychometric properties of an instrument for the measurement of self-neglect (SN).Conceptual Framework: An elder self-neglect (ESN) conceptual framework guided the literature review and scale development. The framework has two key dimensions physical/psycho-social and environmental and seven sub dimensions which are representative of the factors that can contribute to intentional and unintentional SN. Methods: A descriptive cross-sectional design was adopted to achieve the research aim. The study was conducted in two phases. Phase 1 involved the development of the questionnaire content and structure. Phase 2 focused on establishing the psychometric properties of the instrument. Content validity was established by a panel of 8 experts and piloted with 9 health and social care professionals. The instrument was subsequently posted with a stamped addressed envelope to 566 health and social care professionals who met specific eligibility criteria across the four HSE areas. A total of 341 questionnaires were returned, a response rate of 60% and 305 (50%) completed responses were included in exploratory factor analysis (EFA). Item and factor analyses were performed to elicit the instruments underlying factor structure and establish preliminary construct validity. Findings: Item and factor analyses resulted in a logically coherent, 37 items, five factor solution, explaining 55.6% of the cumulative variance. The factors were labelled: ‘Environment’, ‘Social Networks’, ‘Emotional and Behavioural Liability’, ‘Health Avoidance’ and ‘Self-Determinism’. The factor loadings were >0.40 for all items on each of the five subscales. Preliminary construct validity was supported by findings. Conclusion: The main outcome of this research is a 37 item Self-Neglect (SN-37) measurement instrument that was developed by EFA and underpinned by an ESN conceptual framework. Preliminary psychometric evaluation of the instrument is promising. Future work should be directed at establishing the construct and criterion related validity of the instrument.

Parent-off spring associations in wintering brent geese: parental investment or mutual assistance?

The continued parent-offspring associations in the Eastern Canadian High Arctic light-bellied brent goose Branta bernicla hrota was examined to determine whether this is an example of continued parental investment or mutual assistance. Adults with juveniles spend more than twice as much time being vigilant and aggressive than do those without offspring. The loss of a partner, however, does not result in the remaining parent increasing parental care but does result in increased 'self-care' by the juveniles. Neither parents nor single-parent juveniles appear to pay an energetic cost relative to non-parental adults and two-parent juveniles, respectively. Differences in the feeding distribution of parents and non-parents and equivalent or better physical condition suggests that families are able to maintain access to a superior food supply over the winter. Passive 'assistance' by juveniles may assist in maintaining this position in favoured areas, and this is achieved with little overt aggression. The present study thus provides no data that show a net cost to parents by remaining with their juveniles over the winter period. Thus, mutual assistance might be a better explanation of the prolonged association rather than a period of parental investment with an overall cost.

Risks to home care workers: Professional perspectives

Care at home is fundamental to community care policy, but the simultaneous growth of health and safety regulation has implications for home care services because of the duty of employers towards home care workers. This grounded theory study set in Northern Ireland used data from 19 focus groups and nine semi-structured interviews with a range of health and social services professionals and managers to explore perspectives on planning long term care for older people. Home care workers faced a wide range of hazards in the homes of clients, who themselves were faced with adapting their living habits due to their changing health and care needs and 'risks.' Creative approaches were used to ensure the health and safety of home care workers and simultaneously to meet the choices of clients. Staff experienced feelings of conflict when they judged it necessary to impose their way of providing home care and thus impose their values on clients to create a safe working environment. There was variation between and within organizations in terms of the staff focus on client needs or on their employer responsibility towards home care workers. The planning of home care services must take account of both the choices of clients and the hazards facing home care staff.

Holding eternity in an hour: A practical exploration of the arts in the health care of older people with dementia

This project involved creative artists working with older people with dementia and staff from two Belfast Health and Social Care Trust supported housing centres in a mixed programme of dance, painting, music and drama which culminated in an open workshop with relatives and friends of the tenants. The study steered away from traditional medical models of art/music/dance therapy where the participant is perceived as a ‘patient’ in favour of identifying the participant as a ‘student’ who avails of a life-long learning experience. A key premise was that access to the arts is a human right, especially in the context of advancing age and cognitive impairment. . According to one the tenants of Mullan Mews, the project served to ‘awaken - or reawaken - folk with dementia to the endless vista of possibility already in their lives if they will only look for it’. A phenomenographic analysis of video data generated by the project emphasises the importance of the individual experiences of participants in the programme. The evidence from these storylines gained strength from the development of a documentary-style film text that has proved successful in capturing and translating the live experience of the project participants into a supportive text that goes beyond the written word.

The contribution of the United Nations Convention on the Rights of the Child to understanding and promoting the interests of young people making the transition from care to adulthood

The United Nations Convention on the Rights of the Child (UNCRC) acknowledges that young people without parental care are entitled to special support and assistance from the State. In detailing their expectations, the UN Committee have issued Guidelines for the Alternative Care of Children which recognise that State parties have a number of responsibilities towards care leavers. The paper explores how the UNCRC reporting process, and guidelines from the Committee outlining how States should promote the rights of young people making the transition from care to adulthood, can be used as an instrument to track global patterns of change in policy and practice. Content analysis of State Party Reports and Concluding Observations from 15 countries reveals that to date there has been limited engagement with understanding and promoting the needs of this group in the reporting process; although where a government is committed to developing legislation and practice then this does find its way into their national reports. Data supplied by affiliates of the International Research Network on Transitions to Adulthood from Care (INTRAC) reveals that national concerns, political ideology, public awareness, attitudes and knowledge of the vulnerability of care leavers influence service responses to protect and promote the rights of this group and the attention afforded to such issues in reports to the Committee. Findings also suggest that global governance is not simply a matter of top down influence. Future work on both promoting and monitoring of the impact of the UNCRC needs to recognise that what is in play is the management of a complex global/national dynamic with all its uneven development, levels of influence and with a range of institutional actors involved.

Older people's views of support services in response to elder abuse in communities across Ireland

Purpose – This paper seeks to present findings from the first all-Ireland study that consulted older people on their perceptions of interventions and services to support people experiencing abuse.

Design/methodology/approach – Utilising a grounded theory approach, 58 people aged 65 years and over took part in focus groups across Ireland. Four peer-researchers were also trained to assist in recruitment, data collection, analysis, and dissemination.

Findings – Participants identified preventative community-based approaches and peer supports as important mechanisms to support people experiencing, and being at risk of, elder abuse. Choices regarding care provision and housing, as well as opportunities for engagement in community activities where they can discuss issues with others, were identified as ways to prevent abuse.

Originality/value – The development of elder abuse services has traditionally been defined from the perspective of policy makers and professionals. This study looked at the perspective of the end-users of such services for the first time. The research also gave an active role to older people in the research process. The policy implication of the findings from this research is that enhanced attention and resources should be directed to community activities that enable older people to share their concerns informally thereby gaining confidence to seek more formal interventions when necessary.

Evaluating the effectiveness of community-based dementia care networks:The Dementia Care Networks' Study

Purpose: The Dementia Care Networks' Study examined the effectiveness of four community-based, not-for-profit dementia networks. The study involved assessing the relationship between the types of administrative and service-delivery exchanges that occurred among the networked agencies and the network members' perception of the effectiveness of these exchanges. Design and Methods: With the use of a case-study method, the evolution, structure, and processes of each network were documented. Social network analysis using a standardized questionnaire completed by member agencies identified patterns of administrative and clinical exchanges among networked agencies. Results: Differences were found between the four networks in terms of their perceptions of service-delivery effectiveness; perceptions of administrative effectiveness did not factor significantly. Exchanges between groups of agencies (cliques) within each of the four networks were found to be more critical than those between individual agencies within each network. Implications: Integration-measured by the types of exchanges within as opposed to across networks-differentiated the four networks studied. This research contributes to our understanding of the use of multiple measures to evaluate the inner workings of service delivery and their impact on elder health and elder health care. Copyright 2005 by The Gerontological Society of America.

Older adults awareness of community health and support services for dementia care

The article examines where older adults seek help in caring for a parent with dementia and the factors associated with their identification of community health and support services as sources of assistance. The authors conducted telephone interviews, using random digit dialing, of 1,152 adults aged 50 and over in the city of Hamilton. Respondents received a vignette that raised issues related to parental dementia. In identifying support sources, over 37 per cent of respondents identified their physician, 33 per cent identified informal support such as family and neighbors, and 31 per cent identified home health services. Only 18 per cent identified community support services. Female participants having higher levels of education were more likely to identify their physician as a source of support. Knowing where to find information about community support services was associated with an increased likelihood of mentioning physicians and home health services as sources of assistance. © 2009 Copyright Canadian Association on Gerontology.

Evidence-Based Clinical Pathways To Manage Urinary Tract Infections in Long-Term Care Facilities:A Qualitative Case Study Describing Administrator and Nursing Staff Views

Objectives: This article examines the views of nursing staff and administrators in long-term care facilities (LTCFs) regarding a clinical pathway for managing urinary tract infections (UTIs) in LTCF residents. Design: A qualitative (case study) design was used. Setting: Data were collected from 8 LTCFs in southern Ontario and 2 in Iowa enrolled in a larger randomized controlled trial of clinical pathway for managing UTIs in LTCF residents, conducted between September 2001 and March 2003. The clinical pathway, designed to more effectively identify, diagnose, and treat UTIs, and reduce inappropriate antibiotics use for asymptomatic UTIs, introduced 2 decision tools to determine when to order a urine culture and initiate antibiotic treatment for suspected UTIs. Participants: We conducted 19 individual interviews with administrators and 10 focus groups with 52 nurses. Findings: Nurses generally thought that the pathways were well developed and easy to use, and administrators believed they were an important educational resource. Barriers to their use varied by group-initial lack of buy-in from nurses (medical directors), additional work (directors of nursing), and the need to change the protocol to exclude certain residents based on prior health conditions and/or pressure from physicians or families (nurses). Conclusions: Both administrators and staff, once familiar with a new clinical protocol to improve UTI management in LTCFs, generally supported its use. © 2007 American Medical Directors Association.

Active carers: living with chronic obstructive pulmonary disease

It has long been recognised that the majority of care provided in chronic illness comes not from health and social care professionals, but from family and friends. One such illness is chronic obstructive pulmonary disease (COPD), a leading cause of morbidity and mortality in the developed world.To explore the specific care needs of informal caregivers of patients with advanced COPD, interviews were conducted with seven active family caregivers. Interviews were taped, transcribed and content analysed to obtain the caregivers' needs. Results confirm that family caregivers provide direct care with little support and assistance. Participants reported restricted activities of daily living and some emotional distress. There were knowledge deficiencies among caregivers relating to the COPD illness trajectory and little awareness of the potential of palliative care. Family caregivers need social and professional support while caring for a patient at home. This would help to ensure that their physical and emotional health does not suffer. There is a need to devise interventions to ensure family caregivers are supported.

Would people with Parkinson's disease benefit from palliative care?

Parkinson's disease (PD) is a chronic, progressive, degenerative disorder of the nervous system, causing substantial morbidity and has the capacity to shorten life. People with PD and their families can find the disease devastating. Nevertheless, this population of patients is not usually considered a group to be supported by palliative care specialists. But the nature of the illness and the challenges of managing its many physical and psychological effects raises questions about the potential benefits of a palliative care approach. The purpose of this project was to describe the experience of PD and consider the relevance of palliative care for this population. Semi-structured interviews were conducted with eight people with PD, 21 family caregivers and six health professionals. Five themes were developed from the data analysis: (1) emotional impact of diagnosis; (2) staying connected; (3) enduring financial hardship; (4) managing physical challenges; and (5) finding help for advanced stages. These data revealed that people with PD and family caregivers are confronted with similar issues to people with typical palliative care diagnoses, such as advanced cancer, and that a palliative approach may be helpful in the care of people with PD and their families.

The experience of research participation for family caregivers of palliative care cancer patients

There have been concerns raised regarding the ethical merit of involving dying patients and family caregivers as research participants. This study sought feedback from 103 primary family caregivers who had participated in a longitudinal research project. Caregivers were sent a questionnaire regarding the benefits and negative aspects associated with participating in research while also supporting or having supported a relative dying of cancer. The study identified that almost three quarters (71.1%) of the 45 respondents reported benefits of being involved in research and the majority (88.9%) cited no negative aspects associated with research participation. Findings of the study suggest that it is pertinent to invite family caregivers to be involved in palliative care research. Moreover, this study demonstrated that not only is it probably safe for family caregivers to be involved in research but also that many participants actually derive benefits.