NURSES’ ATTI TUDI NAL AND NORMATI VE BELI EFS CONCERNI NG HEMODYNAMI C
ASSESSEMENT BY PULMONARY ARTERY CATHETERI ZATI ON
1Cr ist iano José Mendes Pint o2 Rober t a Cu n h a Rodr igu es Colom bo3 Mar ia Cecília Bueno Jay m e Gallani3
Pin t o CJM, Colom bo RCR, Gallan i MCBJ. Nu r ses’ at t it u din al an d n or m at iv e belief s con cer n in g h em ody n am ic
assessem en t b y p u lm on ar y ar t er y cat h et er izat ion . Rev Lat in o- am En f er m ag em 2 0 0 6 n ov em b r o- d ezem b r o; 1 4 ( 6 ) : 9 1 5 - 2 2 .
The obj ect ive of t his st udy w as t o ident ify, by using t he Theor y of Reasoned Act ion/ Theor y of Planned Behav ior , t he at t it ude and nor m at iv e beliefs t hat influence t he behav ior al int ent ion of t he nur se t o per for m a h em od y n am ic assessm en t u sin g t h e p u lm on ar y ar t er y cat h et er izat ion . Dat a w er e collect ed t h r ou g h sem i-st r uct ur ed int er v iew s inv olv ing 2 3 nur ses fr om t hr ee hospit als in t he cit y of Cam pinas, São Paulo. The dat a w er e analy zed accor ding t o a qualit at iv e m et hodology . Am ong t he At t it ude Beliefs, affect iv e beliefs and t hose r elat ed t o t h e adv an t ages an d disadv an t ages of per f or m in g t h e beh av ior st an d ou t . Am on g t h e Nor m at iv e Beliefs social r efer en t s w er e iden t ified for t h e beh av ior , as w ell as t h e beh av ior - st im u lat in g fact or s an d t h e fact or s t hat discour age t he per for m ance of t he behav ior .
DESCRI PTORS: nur sing car e; int ensiv e car e; cat het er izat ion, Sw an- Ganz; behav ior
CREEN CI AS N ORMATI VAS Y DE ACTI TUD DE LOS EN FERMEROS SOBRE EL ESTUDI O
HEMODI NÁMI CO POR MEDI O DEL CATÉTER DE ARTERI A PULMONAR
El obj et iv o de est e est udio fue ident ificar , por m edio de la Teor ía del Com por t am ient o Planificado, las cr eencias nor m at iv as y de act it ud que cont r ibuy en par a la for m ación de la int ención de com por t am ient o del enfer m er o en r ealizar el est udio hem odinám ico ( EH) por m edio del cat ét er de la ar t er ia pulm onar . Los dat os fuer on obt enidos at r av es de ent r ev ist a sem i est r uct ur ada de 23 enfer m er os de unidades de t er apia int ensiv a de t r es h ospit ales del m u n icipio de Cam pin as- São Pau lo. Los dat os f u er on an alizados segú n la m et odología cu alit at iv a. En t r e las Cr een cias d e Act it u d se d est acar on las cr een cias af ect iv as y aq u ellas r elat iv as a las v ent aj as y desv ent aj as de la r ealización del com por t am ient o. En las Cr eencias Nor m at iv as se ev idenciar on los r efer ent es sociales par a la ej ecución del com por t am ient o, así com o fact or es est im ulant es y que no est im ulan la r ealización del EH.
DESCRI PTORES: cuidados de enfer m er ía; cuidados int ensiv os; cat et er ism o de Sw an- Ganz; conduct a
CRENÇAS ATI TUDI NAI S E NORMATI VAS DOS ENFERMEI ROS SOBRE O ESTUDO
HEMODI NÂMI CO POR MEI O DO CATETER DE ARTÉRI A PULMONAR
O obj et ivo dest e est udo foi ident ificar , por m eio da Teor ia da Ação Racional/ Teor ia do Com por t am ent o Planej ado, as cr enças de at it ude e nor m at iv as que cont r ibuem par a a for m ação da int enção com por t am ent al do en f er m eir o em r ealizar o est u do h em odin âm ico ( EH) por m eio do cat et er de ar t ér ia pu lm on ar ( CAP) . A colet a de dados foi r ealizada por m eio de ent r ev ist a sem i- est r ut ur ada j unt o a 23 enfer m eir os de unidades de t er apia int ensiva de t r ês hospit ais do m unicípio de Cam pinas, SP. Os dados for am analisados segundo m et odologia qualit at iv a. Dent r e as cr enças de at it ude dest acar am - se as cr enças afet iv as e aquelas r elat iv as às v ant agens e desv an t agen s da r ealização do com por t am en t o. Nas cr en ças n or m at iv as for am ev iden ciados os r efer en t es sociais par a a ex ecução do com por t am ent o, bem com o fat or es est im ulador es e desest im ulador es da r ealização do EH.
DESCRI TORES: cu idados de en fer m agem ; cu idados in t en siv os; cat et er ism o de Sw an - Gan z; com por t am en t o
1 Paper ext r act ed fr om t he Mast er ´ s Thesis; 2 RN, I nt ensive Ther apy Unit , Cam pinas St at e Univer sit y Hospit al de Clínicas, M.Sc. in Nur sing, e- m ail:
cr im endes2005@yahoo.com .br ; 3 RN, Assist ant Pr ofessor, Cam pinas St at e Univer sit y Facult y of Medical Sciences
I NTRODUCTI ON
S
afe, r apid and r eliable bedside m onit or ing o f p h y si o l o g i ca l p a r a m et er s t h r o u g h a p u l m o n a r ya r t e r y c a t h e t e r ( PAC) h a s b e c o m e e s s e n t i a l f o r
m a n a g i n g cr i t i ca l p a r t i e n t s i n t h e l a st 3 0 y e a r s.
How ever, at t he end of t he 1980’s, t he fir st inquir ies
were raised about it s use, as st udies( 1- 2) report ed higher m or t alit y r at es am on g p at ien t s m on it or ed w it h t h e
cat het er, leading t o recom m endat ions t o suspend PAC
use( 3). The lack of r andom ized r esear ch in t his ar ea m ade scien t if ic societ ies an d specialist s r ecom m en d
r andom ized st udies t o pr ov e PAC efficacy( 4).
Re c e n t s t u d i e s a t e v i d e n c e l e v e l I w e r e
i n co n cl u si v e ab o u t PAC ef f i cacy( 5 - 6 ). Nev er t h el ess, lit er at u r e r ep or t s t h at h ealt h p r of ession als’ lim it ed
k n o w l ed g e o n PAC m an ag em en t ( 7 - 9 ) h as i m p ai r ed ca t h et er ef f i ca cy a ssessm en t . Hen ce, ed u ca t i o n a l
p r o g r am s h av e b een r eco m m en d ed t o t r ai n t h ese
pr ofessionals in or der t o int er pr et t he hem ody nam ic
v ar iables pr ov ided by t he PAC( 9- 10).
Cr i t i c a l c a r e n u r s e s f r e q u e n t l y m e n t i o n
d if f icu lt ies t o car r y ou t h em od y n am ic st u d ies ( HS)
using PAC, as w ell as t he underut ilizat ion of obt ained
dat a in nur sing car e planning.
St udies have been realized t o ident ify nur ses’
t echnical and concept ual k now ledge about t he PAC(
7-8)
, bu t t h er e ar e n o r epor t s on w h at con dit ion s an d
k n ow led g e t h ey con sid er n ecessar y t o p er f or m HS.
As h ealt h b eh av ior s d o n ot ex clu siv ely d ep en d on
know ledge, it is im por t ant t o get t o know w hat fact or s
cont ribut e t o t he form at ion of nur ses’ behavior al int ent
t o per for m HS.
Am ong t heories t hat st udy behavior, t he Theory
of Reasoned Act ion( 11) ( TRA) st ands out . According t o t h ese fr am ew or k s, t h e in t en t ion t o r ealize a cer t ain
behavior is a funct ion of t he following fact ors: 1. At t it ude
– f or m ed by at t it u din al belief s, w h ich r ef er s t o t h e
in d iv id u al’s p osit iv e or n eg at iv e assessm en t of t h e
consequences of behav ior ; and 2. Subj ect iv e Nor m
-form ed by norm at ive beliefs, which refers t o percept ion
of t he social pressure t o perform t he behavior.
I t is pr esupposed t hat behav ior is a funct ion
o f sa l i e n t i n f o r m a t i o n o r b e l i e f s r e l e v a n t f o r i t s
occu r r en ce. Hen ce, a d eep er u n d er st an d in g of t h e
beliefs people develop t hr oughout t heir lives pr ovides
f u n d a m e n t a l su p p o r t t o o b t a i n i n f o r m a t i o n a b o u t
b eh av i o r al d et er m i n an t s, as t h ese b el i ef s m ak e i t
possible t o recognize fact or s inducing a per son t o get
involv ed ( or not ) in a cer t ain behav ior.
The ident ificat ion of fact ors cont ribut ing t o t he
for m at ion of nur ses’ behav ior al int ent ion t o per for m
HS can suppor t t he out lining of effect iv e educat ional
in t er v en t ion s, w h ich w ill con seq u en t ly r esu lt in t h e
opt im izat ion of nursing care qualit y for crit ical pat ient s
m on it or ed t h r ou gh PAC. Th is st u dy aim s t o pr esen t
t he TRA elem ent s, t hat is, t he at t it udinal and norm at ive
b elief s t h at con t r ib u t e t o t h e f or m at ion of n u r ses’
behavioral int ent ion t o perform HS by m eans of PAC.
CASUI STI CS AND METHOD
Place of st udy
Dat a w er e collect ed at adu lt I n t en siv e Car e
Un it s ( I CUs) of t w o pu blic an d on e pr iv at e h ospit al
locat ed in Cam pinas, a lar ge ur ban cent er w it h about
one m illion inhabit ant s in t he Sout heast of Br azil.
Su b j ect s
Part icipant s w ere 23 nurse clinicians w ho had
deliv er ed car e t o at least t h r ee PAC pat ien t s in t h e
last four m ont hs and agr eed t o par t icipat e by signing
t he. Pr ofessionals on healt h leav e or any ot her leav e
of absence w er e excluded. The sam pling pr ocess w as
int ent ional, using t he sat urat ion crit erion t o det erm ine
sam ple size( 12).
Dat a collect ion
Dat a w er e collect ed t h r ou gh sem ist r u ct u r ed
int er v iew s, using an inst r um ent st r uct ur ed accor ding
t o TRA p r e m i s e s a n d s u b m i t t e d t o c o n t e n t
validat ion( 12). Seven exper t s w it h r enow ned know ledge in crit ical pat ient care evaluat ed t he inst rum ent by. A
pret est w as perform ed w it h t hree nurse clinicians from
adult I TUs t o assess t he int er v iew ees’ under st anding
of t he inst r um ent . I nt er v iew s w er e held indiv idually,
pr ot ect in g su bj ect s’ pr iv acy, t aper ecor ded an d lat er
t r anscr ibed. All subj ect s enr olled signed t he Fr ee and
I nfor m ed Consent Ter m and t he st udy w as appr ov ed
by t he local Resear ch Et hics Com m it t ee.
Dat a an aly sis
D a t a w e r e a n a l y s e d u s i n g a q u a l i t a t i v e
appr oach( 13), accor ding t o t he follow ing st eps: 1 . Tr an scr i p t i o n , r ead i n g an d r er ead i n g o f
in t er v iew s, h ig h lig h t in g m ean in g s t h at an sw er ed t o
t he pr oposed inquir ies; 2. Com par ison am ong differ ent
subj ect s’ discour se t o ident ify t he com m on and m ost
m eaning; 3. Gr ouping of unit s of m eaning int o t hem at ic
subcat egor ies; 4. Gr ouping of t hem at ic subcat egor ies
int o cent r al t hem at ic cat egor ies, a pr ior i est ablished
accor ding t o TRA pr em ises, w it hin t he t hem at ic unit s
cor r espon din g t o TRA con st r u ct s.
RESULTS
Th e 2 3 su b j ect s w er e m ain ly w om en ; w it h
m ean age 32.2 ( ± 6.6) year s, aver age gr aduat ion t im e
8 . 0 ( ± 5 . 6 ) y ear s, an d w it h len gt h of ex per ien ce in
I CU o f 5 . 1 ( ± 4 . 8 ) y e a r s. Fi f t y su b j e ct s ( 6 5 . 2 % )
m e n t i o n e d a l a t o s e n s u p o s t g r a d u a t e l e v e l o f
sch oolin g .
Th e b e l i e f s r e l a t e d t o H S p e r f o r m a n c e
behav ior ar e pr esent ed accor ding t o t he t w o Cent r al
Th e m a t i c Un i t s, w h i ch w e r e a p r i o r i e st a b l i sh e d
a cco r d i n g t o TRA e l e m e n t s a n d t h e i r r e sp e ct i v e
Cen t r al Th em e Cat egor ies ( Table 1 ) .
Table 1 - Synopt ic t able of cent ral t hem at ic unit s: At t it udinal and norm at ive beliefs and t heir respect ive cent ral
t h em e cat eg or ies
s t i n u c i t a m e h t l a r t n e
C Attitudinalbeliefs Normativebeliefs
s e i r o g e t a C e m e h T l a r t n e C S H g n i z il a e r f o s e g a t n a v d
A SocialreferentsstimulatingthereailzationofHS S H g n i z il a e r f o s e g a t n a v d a s i
D SocialreferentsdiscouragingthereailzationofHS
H E o d o ã ç a z il a e r à o ã ç a l e r m e s a v i t e f a s a ç n e r
C FatoresqueestimulamareailzaçãodoEH H E o d o ã ç a z il a e r a m a l u m i t s e s e d e u q s e r o t a F
Them at ic Unit : At t it udinal beliefs
Adv ant ages of r ealizing HS
The analysis of answ er s about t he advant ages
evidenced t he subcat egor ies: Advant ages for pat ient s,
Advant ages for Physicians and Advant ages for nur ses.
I n r e l a t i o n t o t h e p a t i e n t s , t h e a n a l y s i s
r ev ealed t h at on e of t h e ad v an t ag es of PAC is t h e
possibilit y of guiding t reat m ent w it h precision, as PAC
u se p er m it s ob t ain in g accu r at e h em od y n am ic d at a.
Th i s c o n t r i b u t e s t o d e f i n e t h e d i a g n o s i s , g u i d e
t her apeut ical conduct and m edicat ion use. As t o t he
Advant ages for phy sicians subcat egor y, w e obser v ed
t hat t he sam e unit s of m eanings as in Advant ages for
pat ient s w er e r epr oduced. Am ong t he few Advant ages
f o r n u r s e s , c o n t r i b u t i o n t o n u r s i n g c a r e a n d t o
pr ofessional lear ning st ood out .
Disadv an t ages of r ealizin g HS
Figur e 1 - Cent r al t hem e cat egor y : Disadv ant ages of t he behav ior &+5#&8#06#)'5
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Th e su b ca t e g o r i e s g r o u p e d i n t h i s t h e m e
cat egory are present ed in Figure 1. I nfect ion risk was
t he m ost prevalent subcat egory in subj ect s’ discourse,
an d w as st r on gly associat ed w it h ex t en ded cat h et er
dw elling t im e and inadequat e cat het er handling. The
m edical t eam was considered responsible for ext ended
cat het her dwelling t im e, which can lead t o t he possible
o b t e n t i o n o f u n r e l i a b l e h e m o d y n a m i c d a t a a n d ,
consequent ly, inadequat e t herapeut ic conduct s: ...m any
people don’t know how t o use it ,... t he cat het er should be kept in
place for a specific t im e, t hen t here’s people who want t o leave it
for 5- 6 days... t hen t he value is no longer reliable and...in fact , t hat
cat het er j ust cont inues as a way of infect ion, and does t he pat ient
m ore harm ... because t hen he can produce a changed value, and
m isleading m edical decisions regarding t he t reat m ent ( E1) .
D i s a d v a n t a g e s o f p e r f o r m i n g H S w e r e
frequent ly associat ed wit h t he increase in nurses’ work
d e m a n d s . Pe r f o r m i n g h e m o d y n a m i c s t u d i e s i s
su pposed t o ov er load n u r ses, as it im plies h an dlin g
new equipm ent , requiring t echnique and t raining. Lack
of equipm ent handling skills and inexist ence of t raining
program s lead t o t im e loss, as t hey cont ribut e t o delays
in t he ex ecut ion of ot her act iv it ies. These m eanings
co n t r i b u t e t o t h e f a ct t h a t p e r f o r m i n g HS i s n o t
considered a priorit y in nursing care for crit ical pat ient s.
Reduced PAC handling skills were associat ed wit h fear
of care delivery t o pat ient s m onit ored w it h a PAC: . . .
everybody’s afraid of taking, of assum ing the patient, why? Because
t hen, at t he t im e of t he st udy, you’ll have t o handle t he m achine,
and t hey’re so afraid,... afraid of t he m achine, / .../ if you t ake care
like wit h any ot her cat het er, t he m achine in it self, t he m axim um
t hat can happen is t hat you’ll have t o do it several t im es... ( E3) .
Affeciv e Beliefs r elat ed t o r ealizing HS
Figur e 2 - Cent r al t hem e cat egor y : Affect iv e Beliefs
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The subcat egor ies associat ed w it h t his t hem e
cat egor y ar e pr esent ed in Figur e 2. A negat ive affect
in r elat ion t o t h e r ealizat ion of HS w as ev id en ced ;
f e e l i n g s l i k e f e a r, i n s e c u r i t y, c o n c e r n a n d
d i sa p p o i n t m e n t w e r e m e n t i o n e d . I n se cu r i t y w a s
associat ed w it h in ab ilit y t o p er f or m HS in u r g en cy
sit uat ions, leading t o incr eased er r or pr obabilit y. Fear
w as associat ed w it h lack of PAC h an dlin g sk ills an d
w it h nur ses’ lack of know ledge about PAC. The feeling
of disappoint m ent w as linked w it h t he physician’s not
using HS dat a t o guide t her apeut ic conduct . Am ong
p o si t i v e b el i ef s, sat i sf act i o n ab o u t p er f o r m i n g t h e
behav ior st ands out , r elat ed t o cr edibilit y in nur sing
w o r k .
Them at ic unit : Nor m at iv e Beliefs
Social r efer en t s st im u lat in g beh av ior
Nu r ses t h em selv es, p r of ession als u sin g HS
d a t a , p h y si ci a n s a n d p a t i e n t s w e r e i n d i ca t e d a s
posit iv e social r efer en t s. Nu r ses w er e con sider ed as
posit iv e social r efer ent s because t hey ar e int er est ed
Pr o f e s s i o n a l s u s i n g H S d a t a a r e a l s o p o s i t i v e
r e f e r e n t s, a s t h e y st i m u l a t e o t h e r p r o f e ssi o n a l s’
lear n in g .
Ph y sician s st im u lat in g t h e r ealizat ion of HS
c o n s t i t u t e p o s i t i v e r e f e r e n t s b e c a u s e t h e y a r e
perceived as t he ones responsible for request ing t hese
st udies, offer ing lear ning oppor t unit ies t o nur ses and
g i v i n g cr e d i t t o n u r si n g w o r k ; p a t i e n t s, i n t u r n ,
st im ulat e t he realizat ion of HS w hen t hey m ake nurses
a ck n o w l e d g e t h e i r r e sp o n si b i l i t y f o r a p p r o p r i a t e
t r eat m en t w it h in t h e in st it u t ion . For som e su bj ect s,
t her e is nobody st im ulat ing t he behav ior, due t o t he
fact t hat t he pr ocedur e is consider ed as par t of nur ses’
r out ine or dut ies: . . . Nobody ask s, nobody st im ulat es, w e
have our funct ion, of doing t his st udy t o...in order t o im prove t he
clinical sit ut at ion... ( E2) .
Social r efer en t s discou r agin g t h e beh av ior
The m edical t eam , ot her healt h pr ofessionals
w ho do not w or k in t eam s, t he per m anent educat ion
ser v ice and nur se heads w er e indicat ed as negat iv e
social r efer ent s. For som e subj ect s, t her e is nobody
discour aging t he r ealizat ion of HS. The m edical t eam
discou r ages t h e beh av ior w h en t h ey do n ot u se HS
dat a t o guide t r eat m ent , w hen t hey pr esent know ledge
deficit s, w hen t hey dem onst r at e t hat t hey do not like
t o t each an d w h en t h ey do n ot t r u st n u r ses’ w or k :
...Medical ar ea, som et im es you say “ do you w ant m e t o do a
car diac out put ?” t hey say “ ah... t her e’s no need” .. .if he’s not
int er est ed... it ’s discour aging... a lot ( E13) .
The phy sician’s lack of cr edibilit y in nur sing
w or k w as im plicit ly associat ed w it h nur ses’ know ledge
deficit t o handle PAC. Ot her negat iv e social r efer ent s
w er e t h e p er m a n en t ed u ca t i o n ser v i ce a n d n u r se
h ead s, w h ich w er e con sid er ed in ef f icien t in n u r ses’
t e c h n i c a l - s c i e n t i f i c t r a i n i n g . Fo r s o m e o f t h e
i n t e r v i e w e e s , t h e r e i s n o b o d y d i s c o u r a g i n g t h e
p er f or m an ce of HS: t h e d iscou r ag em en t com es. . . f r om
super vision, because... I w asn’t t r ained / .../ Ther e’s ver y lit t le
for nur sing, so if w e w ant som et hing, w e have t o go for it , ask
and gener ally it ’s t o t he doct or ( E5) .
Fact or s st im ulat ing t he behav ior
Figur e 3 - Cent r al t hem e cat egor y : Fact or s st im ulat ing t he behav ior
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su b cat eg or ies associat ed w it h t h is t h em e cat eg or y.
Nu r ses’ r esp on sib ilit y in p at ien t car e is on e of t h e
fact ors t hat st im ulat e t he behavior, as it helps t o guide
t r eat m en t , esp ecially in t er m s of b et t er con t r ol of
v aso act i v e d r u g s, w h i ch w as asso ci at ed w i t h car e
qualit y opt im izat ion: ...it st im ulat es... I need t o know about
w hat ’s going on w it h t he pat ient , ... inclusively because of dr ugs
h an d lin g . . . it is n ot j u st k n ow in g t h e p u lm on ar y ar t er y or
pulm onar y capillar y pr essur e level, I have t o under st and w hat is
happening, know a bit about t he pat ient ’s disease, because t hat
is going t o influence t he r esult s ( E23) .
Th e p h y si ci an ’ s t r u st i n n u r ses’ w o r k w as
causes t he feeling of sat isfact ion. Gr eat er k now ledge
a b o u t H S , o b t a i n e d b y p r a c t i c i n g t h e b e h a v i o r
per iodically, also r ev ealed t o st im ulat e t he behav ior.
Th ese t w o su b cat eg or ies w er e associat ed w it h t h e
opt im izat ion of nur sing car e qualit y.
For som e subj ect s, t her e is not hing st im ulat ing
t he behav ior, since t hey believ e t hat t he nur se only
p er f o r m s HS at t h e d o ct o r ’ s r eq u est . Th i s i n d eed
con t r ibu t es t o h er con sider in g t h e r ealizat ion of t h e
beh av ior as “ obligat or y ”.
Fact or s discou r agin g t h e beh av ior
Figur e 4 - Cent ral t hem e cat egor y : Fact or s discour aging t he behav ior
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(#%6145&+5%174#)+0)6*'$'*#8+14
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Figur e 4 pr esent s t he subcat egor ies and unit s
of m ean in g h igh ligh t ed in t h is cat egor y. On e of t h e
f act or s r ecog n izin g as d iscou r ag in g t h e b eh av ior is
t h e d if f icu lt y t o p er f or m t h e p r oced u r e, f r eq u en t ly
a sso ci a t e d w i t h r e d u ce d sk i l l s a n d e x p e r i e n ce i n
h a n d l i n g h e m o d y n a m i c m o n i t o r i n g m a t e r i a l s a n d
equipm ent , w hich seem s t o cont r ibut e t o t he fact t hat
realizing HS is not considered as a priorit y in nursing
int ervent ions involving crit ical pat ient s: ...w e w ast e t im e...
it delays all of our w or k. So, w hen t her e is a pat ient w it h Sw
an-Ganz, w e end up post poning t he r ealizat ion of t he st udy like,
w hen t he shift alm ost changes, because if you lose t im e... your
shift changes and you leave ( E3) .
Nur ses’ w or k ov er load and k now ledge deficit
abou t PAC w er e also m en t ion ed, t h e lat t er der iv in g
from t he inefficiency of perm anent educat ion services
t o d ev elop t r ain in g an d r ecy clin g p r og r am s, w h ich
m ak es n u r ses at t r ib u t e t h e b eh av ior of p er f or m in g
HS t o t he physician, w hile nurses are only responsible
for helping him t o r ealize t he pr ocedur e: ...it ’s not like a
huge pr oblem , pr ovided t hat you get ... t r aining befor e... ( E22) .
DI SCUSSI ON
Th is st u dy r ev ealed t h e ex ist en ce of beliefs
t hat per m eat e t he behavior of per for m ing HS, bot h in
t er m s of t he subj ect ’s at t it ude t ow ar ds t he behav ior
and t he social r efer ent s t hat st im ulat e or discour age
it s r ealizat ion.
A m o n g p o s i t i v e a t t i t u d i n a l b e l i e f s , t h e
advant ages of using PAC in cr it ical pat ient s st ood out ,
esp ecially w it h r esp ect t o t h eir con t r ib u t ion t o t h e
o u t l i n i n g o f p a t i e n t i n t e r v e n t i o n s . H S ’ p o s i t i v e
c o n t r i b u t i o n t o p a t i e n t t r e a t m e n t , i n t u r n , w a s
associat ed w it h a p osit iv e af f ect in r elat ion t o t h e
behavior, result ing in t ranquilit y in pat ient care. These
f in din gs poin t t ow ar ds t h e ack n ow ledgem en t of t h e
im por t ance of PAC use in pat ient t r eat m ent .
How ever, t his acknow ledgem ent occur s am idst
m any disadvant ages nur ses associat e w it h HS. These
obser v at ions st r engt hen t he pr em ises of t he adopt ed
t heor et ical r efer ence fr am ew or k( 11), according t o w hich a t t i t u d i n a l b e l i e f s a r e f o r m e d f r o m p o si t i v e a n d
negat ive m eanings people at t ach t o t he r ealizat ion of
a beh av ior.
Mo r e o v e r, i n t h e a s s e s s m e n t i n d i v i d u a l s
m a k e b e f o r e p e r f o r m i n g t h e b e h a v i o r, n e g a t i v e
beliefs t end t o ex er t a st r onger im pact t hat posit iv e
b e l i e f s , a n d t h e l a t t e r t e n d t o e x e r c i s e g r e a t e r
in f lu en ce on lon g - t er m d ecision s, w h ile t h e f or m er
ar e m o r e p r ed o m i n an t i n sh o r t - t er m d eci si o n s( 1 4 ). When consider ing t he decision t o per for m HS a shor t
b elief s can in f lu en ce a n eg at iv e m ot iv at ion am on g
nur ses t o r ealize t he behav ior. The disadvant ages of
r ealizin g HS w er e m ain ly associat ed w it h t h e r isk s
o f c a t h e t e r u s e a n d i n c r e a s e d n u r s i n g w o r k
d e m a n d s.
T h e s u b j e c t i v e n o r m s u g g e s t s g r e a t e r
p ossib ilit ies t h at a su b j ect w ill ex ecu t e a b eh av ior
w h en h e b elief s t h at im p or t an t p eop le ex p ect h im
t o p e r f o r m t h e b e h a v i o r( 1 5 ). I n t h i s s t u d y, t h e p h y sician em er g ed as an im p or t an t p osit iv e social
r ef er en t an d w as ack n ow ledged as t h e pr of ession al
w h o t each es an d t r u st s n u r ses’ w or k , con t r ib u t in g
t o t h eir lear n in g .
The unit of m eaning – phy sician’s r equest –
w as t h e m ost salien t in t h e in t er v iew ees’ discou r se
a s a s t i m u l u s t o p e r f o r m H S . Th i s i n f o r m a t i o n
ev idences t hat nur ses r ealize HS on t he basis of t he
phy sician’s assessm ent and at his r equest . For som e
part icipant s, t his w as one of t he only fact ors st im ulat ing
t he behavior. I t seem s incongruent t hat nurses indicat e
t he doct or ’s r equest as a st im ulus t o per for m HS, as
nur ses possess aut onom y t o r ealize HS and t hey ar e
ex pect ed t o in t er pr et t h e collect ed dat a in or der t o
su ppor t n u r sin g in t er v en t ion s.
On t h e ot h er h an d , t h e p h y sician w as also
c o n s i d e r e d a s a n e g a t i v e s o c i a l r e f e r e n t , w h o
d i sco u r a g e s t h e r e a l i za t i o n o f HS, m a i n l y i n t h e
absence of a link w it h m ult ipr ofessional w or k and/ or
w hen he does not know or does not use dat a obt ained
t h r ou gh t h e PAC t o gu ide cr it ical pat ien t t r eat m en t .
Alt hough t he im port ance of t he social referent should
b e a c k n o w l e d g e d t o p e r f o r m c e r t a i n b e h a v i o r s ,
f r equ en t r ef er en ces t o t h e ph y sician as a st im u lu s/
d iscou r ag em en t or ev en m ed iat in g af f ect iv e b elief s
abou t t h e per for m an ce of HS seem t o con t r ibu t e t o
r em o v e n u r ses’ f o cu s f r o m t h ei r r esp o n si b i l i t y t o
per for m and int er pr et HS.
Lack of k now ledge and sk ills in PAC pat ient
car e w er e beliefs t hat per m eat ed t he disadv ant ages
of t he behavior, as w ell as negat ive affect ion w it h HS.
Th e s e p o i n t s t o w a r d s t h e r e l e v a n c e o f n u r s e s ’
scient ific r ecy cling, if not as a det er m inant fact or of
behavior, t hen as a fact or t hat cont ribut es t o t raining
t h e beh av ior, as w ell as t o m ot iv at ion t o per for m it
t hr ough t he developm ent of posit ive affect ion. I n t his
cont ext , t he funct ion of per m anent educat ion ser vices
m u st b e e m p h a si ze d , w h i ch sh o u l d b e e sp e ci a l l y
i m p o r t an t i n n u r ses’ r ecy cl i n g . Ho w ev er, o u r d at a
s h o w e d t h a t p e r m a n e n t e d u c a t i o n s e r v i c e
p r o f e s s i o n a l s a n d n u r s e h e a d s h a v e a l s o b e e n
con sider ed as r ef er en t s discou r agin g t h e r ealizat ion
of HS, par t icular ly due t o t heir inefficiency in helping
n u r s e s t o a c q u i r e a n d i m p r o v e PA C h a n d l i n g
k n ow ledge an d sk ills.
T h e h e a l t h t e a m ’ s i n a d e q u a t e u s e o f
h e m o d y n a m i c d a t a h a s a r o u s e d t h e i n t e r e s t o f
in t er n at ion al scien t if ic societ ies, as t h e k n ow led g e
d ef icit r ef lat ed t o PAC h an d lin g is on e of t h e m ain
f a ct o r s d i f f i cu l t i n g ca t h e t e r e f f i ca cy a sse ssm e n t ,
w h ich h as led t o r ecom m en dat ion s t o im pr ov e t h ese
pr of ession als’ k n ow ledge an d, m ain ly, t o r ev iew an d
m o d i f y t r a i n i n g a n d p e r m a n e n t e d u c a t i o n
m et h o d s( 1 0 ).
Train in g an d per m an en t edu cat ion m et h ods
need t o change, consider ing t hat educat ion pr ogr am s
t o im p r ov e t ech n ical- scien t if ic k n ow led g e h av e n ot
b e e n s a t i s f a c t o r y i n r e t a i n i n g a n d / o r e x p a n i n g
p r o f e ssi o n a l s’ k n o w l e d g e( 1 6 ). Th e i d e n t i f i ca t i o n o f b e l i e f s a n d f a ct o r s i n f l u e n ci n g a d h e r e n ce t o t h e
b eh av ior is essen t ial t o g u id e t h e d ev elop m en t of
i n t e r v e n t i o n p r o g r a m s t h a t co u l d b e e f f e ct i v e i n
opt im izin g an d gu ar an t eein g t h e accom plish m en t of
im p or t an t p r oced u r es or t ech n iq u es in p r of ession al
pr act ice( 15- 17).
Hence, t he r esult s of t his st udy allow us t o
infer t hat t he t eaching m et hods per m anent educat ion
se r v i ce s u se a b o u t PAC m a n a g e m e n t n e e d t o b e
r easesssed and r est r uct ur ed. Thus, it seem s adequat e
t o r ecom m en d t h at ed u cat ion al p r og r am s m ak e an
effort t o provide t echnical- scient ific cont ent s but , also,
t hat t he elabor at ion of such pr ogr am s consider s fact or s
m ot iv at ing, per m it ing and st r engt hening t he nur ses’
behaviors t o adopt a specific behavior. I t is im port ant
for t his r ecy cling t o be dir ect ed at t he dev elopm ent
of clin ical r eason in g , m ak in g n u r ses self - con f id en t
a b o u t t h e i r c o m p e t e n c e a n d , t h e r e f o r e , a b l e t o
part icipat e in decision- m aking processes about crit ical
p a t i e n t c a r e , t o g e t h e r w i t h t h e i r p e e r s a n d t h e
i n t e r d i s c i p l i n a r y t e a m , i n a n e q u a l i t a r i a n a n d
au t on om ou s w ay.
I n a fut ur e st udy, t hese dat a w ill cont r ibut e
t o t he const r uct ion of a psychom et r ic scale t o assess
t h e m a g n i t u d e o f e a c h s e t o f b e l i e f s i n t h e
det er m in at ion of t h is beh av ior. I den t ify in g t h e m ost
in t en se b elief s w ill p er m it t h e d esig n of ed u cat iv e
int er v ent ions aim ed at st r engt hening posit iv e beliefs
an d t r an sf or m in g belief s in a posit iv e sen se f or t h e
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