Referência e contrarreferência na atenção à saúde das pessoas com amputação na visão do enfermeiro: uma perspectiva bioética

Disertação (mestrado) - Universidade Federal de Santa Catarina, Centro de Ciências da Saúde, Programa de Pós-Graduação em Enfermagem, Florianópolis, 2015Introdução: A pessoa com amputação necessita de cuidados dos diferentes níveis de atenção à saúde na perspectiva das redes. O enfermeiro é responsável pelo cuidado e acompanhamento das pessoas com doenças crônicas, dentre estas a hipertensão arterial e o diabetes mellitus, principais causas das amputações eletivas. É, também, gestor do cuidado e deve promover atenção integral à saúde do ser humano, para tal, carece empoderar-se da referência e da contrarreferência para articular os distintos pontos da rede. Objetivos: Descrever a atuação dos enfermeiros no referenciamento e contrarreferenciamento de serviços de saúde às pessoas com amputação; Analisar o processo de referência e contrarreferência na assistência à saúde das pessoas com amputação, na perspectiva dos enfermeiros, sob o olhar da bioética. Metodologia: Estudo exploratório-analítico com abordagem qualitativa. Realizado entrevista semiestruturada com 21 enfermeiros alocados na rede de atenção à saúde de Florianópolis que prestam assistência à pessoa com amputação. Os dados foram organizados com auxílio do software Atlas ti 7.5.6 e analisados com base na análise de conteúdo temática. Aprovado pelo Comitê de Ética, parecer nº 970.902 de 24/02/2015. Resultados: Do primeiro manuscrito: "Atuação do enfermeiro no referenciamento e contrarreferenciamento às pessoas com amputação", emergiram duas categorias temáticas: Portas de entrada da pessoa com amputação; O enfermeiro na assistência e as implicações de sua atuação no referenciamento e contrarreferenciamento. Identificaram-se como portas de entrada as Unidades Básicas de Saúde, o serviço de Emergência e o Centro Catarinense de Reabilitação. Os enfermeiros mostraram-se autônomos e capacitados para realizar a referência e contrarreferência quando necessário, entretanto, o foco inicial é a oferta da assistência mais adequada. No segundo manuscrito: "Referenciamento e contrarreferenciamento à pessoa com amputação: analise da conduta dos enfermeiros na perspectiva bioética", procedeu-se a análise a partir de duas categorias temáticas: Conduta do enfermeiro na perspectiva Bioética de Proteção e de Intervenção; Potencialidades e fragilidades no processo de referência e contrarreferência. Os resultados evidenciaram que sem o respaldo legal, a maioria dos encaminhamentos são realizados com base nas relações interpessoais e na informalidade. A análise sob o olhar da bioética permitiu concluir que não só a pessoa com amputação, mas que o enfermeiro também ocupa posição de vulnerabilidade. Estes mostraram comprometimento ético com a profissão e empenho para oferecer um atendimento integral. O comprometimento ético, a criatividade profissional, o matriciamento e a interconsulta foram pontudas como potencialidades. As fragilidades foram à inexistência de protocolos, a comunicação ineficaz entre os níveis de atenção, o acesso restrito à informação e a lentidão nos referenciamentos. Considerações finais: O enfermeiro é um profissional presente em todos os pontos da rede de atenção à saúde, logo compete a ele o dever de conscientizar-se acerca das políticas públicas de amparo à pessoa com amputação. Há necessidade de padronização das ações na assistência à saúde da pessoa com amputação, por instrumentos que direcionem as ações dos profissionais envolvidos e facilitem o acesso ao usuário do Sistema Único de Saúde. Ferramentas como o InfoSaúde e o Sistema Nacional de Regulação necessitam ser aperfeiçoadas e unificadas em todo território nacional.Abstract : Introduction: The person with amputation needs care of the different health care levels in the perspective of networks. The nurse is responsible for the care and monitoring of people with chronic diseases, among them high blood pressure and diabetes mellitus, major causes of elective amputations. It is also the care manager and should promote comprehensive health care of human beings, to do so, it needs to empower the reference and counter-reference to articulate the different points in the network. Objectives: Describe the role of nurses in referencing and counter-referencing of health services to people with amputations; Analyze the health care process of reference and counter-reference for people with amputation, from the perspective of nurses, on the view of bioethics. Methodology: Exploratory-analytic study with a qualitative approach. Conducted semi structured interviews with 21 nurses allocated in the health care network of Florianópolis that assist the person with amputation. Data were organized with the help of software Atlas ti 7.5.6 and analyzed based on thematic content analysis. Approved by the Ethics Committee, report number 970902 of 02.24.2015. Results: From the first manuscript, "Nurses' performance in referencing and counter-referencing of people with amputation", emerged two thematic categories: Entrance doors of people with amputation; The nurses in care and the implications of its performance in referencing and counter-referencing. Were identified as gateways the Basic Health Units, the Emergency Service and the Santa Catarina Rehabilitation Center. Nurses proved to be autonomous and able to perform the reference and counter-reference when needed, however, the initial focus is to offer the most appropriate assistance. In the second manuscript, "Referencing and counter-referencing to the person with amputation: Analyze of nurses conduct in bioethics perspective," proceeded the analysis from two thematic categories: Conduct of nurses from the bioethics perspective of Protection and Intervention; Strengths and weaknesses in the reference and counter-reference process. The results showed that without legal support, most referrals are made based on interpersonal and informal relations. The analysis from the perspective of bioethics concluded that not only the person with amputantion, but the nurse also occupy a position of vulnerability. These showed ethical commitment to the profession and commitment to offer comprehensive assistance. The ethical commitment, professional creativity, matricial and interconsultation were pointed as potential. The weaknesses were the lack of protocols, ineffective communication between levels of care, restricted access to information and the slowness in referring. Final considerations: The nurse is a professional present at all points of the health care network, so it is up to him the duty to become aware about public policy support to the person with amputation. There is a need to standardize the actions for he person with amputation in health care, for instruments that drive the actions of the professionals involved and facilitate access of the Unified Health System user. Tools like InfoSaúde and the National Regulatory System need to be improved and unified nationwide

Mulheres abrigadas na Casa Lilás

Aim: to characterize the women housed in the Lilas House from February 2009 to June 2016 in Porto Alegre – RS; to identify the services that guide them and if the institution shelters women in situations of violence. Porto Alegre - RS. Method: a descriptive, documentary, quantitative study conducted in July 2016, from the records of women housed in Lilas House. The analysis was performed using descriptive statistics. Results: 146 women were housed for at least three days. The majority of those women had the following characteristics: they were aged between 18 and 39 years old, white, single, with up to four children, incomplete elementary school, unemployed and sent to the Lilás House by Reference Centers of Social Assistance (52.7%) and Public Prosecutor (29.5%). The situation of violence represented 32%. Physical and psychological violence were the most reported by the women. Conclusions: the results of this study contribute to the visibility of the seriousness of the problem of women living in situations of social vulnerability and violence.Objetivos: caracterizar las mujeres albergadas en la Casa Lilás en el período de febrero de 2009 a junio de 2016, en Porto Alegre – RS; identificar los servicios que las encaminan y si la institución alberga mujeres en situación de violencia. Método: estudio descriptivo, documental, de naturaleza cuantitativa, realizado en julio de 2016, en los registros de las mujeres albergadas en la Casa Lilás. Análisis realizado por medio de la estadística descriptiva. Resultados: 146 mujeres fueron albergadas por no mínimo tres días. La mayoría entre 18 y 39 años de edad, blancas, solteras, con hasta cuatro hijos, enseñanza fundamental incompleta, desempleada y encaminada a la Casa Lilás por Centros de Referencia de Asistencia Social (52,7%) y Ministerio Público (29,5%). La situación de violencia representó 32%. Las violencias físicas y psicológicas fueron las más relatadas. Conclusiones: los resultados de este estudio contribuyen para tornar visible la gravedad de la problemática de las mujeres que viven en situación de vulnerabilidad social y violencia.Objetivos: caracterizar as mulheres abrigadas na Casa Lilás no período de fevereiro de 2009 a junho de 2016, em Porto Alegre – RS; identificar os serviços que as encaminham e se a instituição abriga mulheres em situação de violência. Método: estudo descritivo, documental, de abordagem quantitativa realizada em julho 2016, nos registros das mulheres abrigadas na Casa Lilás. Análise realizada por meio da estatística descritiva. Resultados: 146 mulheres foram abrigadas por, no mínimo, três dias. A maioria entre 18 e 39 anos de idade, brancas, solteiras, com até quatro filhos, ensino fundamental incompleto, desempregadas e encaminhadas à Casa Lilás por Centros de Referência de Assistência Social (52,7%) e Ministério Público (29,5%). A situação de violência representou 32%. Violências física e psicológica foram as mais relatadas. Conclusões: os resultados deste estudo contribuem para visibilizar a gravidade da problemática das mulheres que vivem em situação de vulnerabilidade social e violência

Competências do profissional da saúde para o cuidado da pessoa com amputação

Aim: to analyze how the health professionals' competence is expressed on the care for the amputee patient. Method: exploratory and descriptive study, conducted in five public hospitals in Florianópolis. Semi-structured interviews were conducted among 19 health professionals from December 2012 to March 2013. The results were analyzed according to content analysis. Results: The technical competence was predominant, since it comes from a training that prioritizes technical and scientific knowledge. The organizational or methodical competence in the health professionals' action is evidenced by the ability of self-organization and self planning with flexibility and creativity in action. Communicative and socio-political competences need to be developed. Conclusion: although participants expressed awareness of the ethical and social implications of their work commitment, there is no autonomy of action.: Objetivo: analizar cómo el profesional de salud se expresa en la atención a la persona con amputación. Método: estudio descriptivo y exploratorio, realizado en cinco hospitales públicos de Florianópolis. Fueron realizadas entrevistas semiestructuradas con 19 profesionales de salud desde diciembre 2012 hasta marzo 2013. Los resultados fueron analizados según el análisis de contenido. Resultados: predomina la competencia técnica, oriunda de una formación que prioriza el conocimiento técnico-científico. La competencia organizacional o metódica en la acciones de los profesionales de la salud es evidenciada por la capacidad de autoplaneamiento e auto-organización con flexibilidad y creatividad en las acciones. La competencia comunicativa y la competencia sociopolítica necesitan ser desarrolladas. Conclusiones: a pesar de los participantes manifestar consciencia de las implicaciones éticas y del compromiso social de su trabajo, no existe autonomía en su acción.Objetivo: analisar de que modo a competência do profissional da saúde se expressa no cuidado à pessoa com amputação. Método: estudo exploratório descritivo, desenvolvido em cinco hospitais públicos da grande Florianópolis. Realizado entrevista semiestruturada com 19 profissionais da saúde no período de dezembro de 2012 a março de 2013. Os resultados foram analisados na perspectiva da análise de conteúdo. Resultados: predomina a competência técnica, oriunda de uma formação que prioriza o conhecimento técnico-científico. A competência organizacional ou metódica nas ações dos profissionais da saúde é evidenciada pela capacidade de autoplanejamento e auto-organização com flexibilidade e criatividade nas ações. A competência comunicativa e a competência sociopolítica precisam maior desenvolvimento. Conclusão: apesar dos participantes manifestarem consciência das implicações éticas e do compromisso social do seu trabalho, não há autonomia de ação

In COVID-19 Health Messaging, Loss Framing Increases Anxiety with Little-to-No Concomitant Benefits: Experimental Evidence from 84 Countries

The COVID-19 pandemic (and its aftermath) highlights a critical need to communicate health information effectively to the global public. Given that subtle differences in information framing can have meaningful effects on behavior, behavioral science research highlights a pressing question: Is it more effective to frame COVID-19 health messages in terms of potential losses (e.g., "If you do not practice these steps, you can endanger yourself and others") or potential gains (e.g., "If you practice these steps, you can protect yourself and others")? Collecting data in 48 languages from 15,929 participants in 84 countries, we experimentally tested the effects of message framing on COVID-19-related judgments, intentions, and feelings. Loss- (vs. gain-) framed messages increased self-reported anxiety among participants cross-nationally with little-to-no impact on policy attitudes, behavioral intentions, or information seeking relevant to pandemic risks. These results were consistent across 84 countries, three variations of the message framing wording, and 560 data processing and analytic choices. Thus, results provide an empirical answer to a global communication question and highlight the emotional toll of loss-framed messages. Critically, this work demonstrates the importance of considering unintended affective consequences when evaluating nudge-style interventions

A global experiment on motivating social distancing during the COVID-19 pandemic

Finding communication strategies that effectively motivate social distancing continues to be a global public health priority during the COVID-19 pandemic. This cross-country, preregistered experiment (n = 25,718 from 89 countries) tested hypotheses concerning generalizable positive and negative outcomes of social distancing messages that promoted personal agency and reflective choices (i.e., an autonomy-supportive message) or were restrictive and shaming (i.e., a controlling message) compared with no message at all. Results partially supported experimental hypotheses in that the controlling message increased controlled motivation (a poorly internalized form of motivation relying on shame, guilt, and fear of social consequences) relative to no message. On the other hand, the autonomy-supportive message lowered feelings of defiance compared with the controlling message, but the controlling message did not differ from receiving no message at all. Unexpectedly, messages did not influence autonomous motivation (a highly internalized form of motivation relying on one’s core values) or behavioral intentions. Results supported hypothesized associations between people’s existing autonomous and controlled motivations and self-reported behavioral intentions to engage in social distancing. Controlled motivation was associated with more defiance and less long-term behavioral intention to engage in social distancing, whereas autonomous motivation was associated with less defiance and more short- and long-term intentions to social distance. Overall, this work highlights the potential harm of using shaming and pressuring language in public health communication, with implications for the current and future global health challenges

A multi-country test of brief reappraisal interventions on emotions during the COVID-19 pandemic

The COVID-19 pandemic has increased negative emotions and decreased positive emotions globally. Left unchecked, these emotional changes might have a wide array of adverse impacts. To reduce negative emotions and increase positive emotions, we tested the effectiveness of reappraisal, an emotion-regulation strategy that modifies how one thinks about a situation. Participants from 87 countries and regions (n = 21,644) were randomly assigned to one of two brief reappraisal interventions (reconstrual or repurposing) or one of two control conditions (active or passive). Results revealed that both reappraisal interventions (vesus both control conditions) consistently reduced negative emotions and increased positive emotions across different measures. Reconstrual and repurposing interventions had similar effects. Importantly, planned exploratory analyses indicated that reappraisal interventions did not reduce intentions to practice preventive health behaviours. The findings demonstrate the viability of creating scalable, low-cost interventions for use around the world

A multi-country test of brief reappraisal interventions on emotions during the COVID-19 pandemic.

The COVID-19 pandemic has increased negative emotions and decreased positive emotions globally. Left unchecked, these emotional changes might have a wide array of adverse impacts. To reduce negative emotions and increase positive emotions, we tested the effectiveness of reappraisal, an emotion-regulation strategy that modifies how one thinks about a situation. Participants from 87 countries and regions (n = 21,644) were randomly assigned to one of two brief reappraisal interventions (reconstrual or repurposing) or one of two control conditions (active or passive). Results revealed that both reappraisal interventions (vesus both control conditions) consistently reduced negative emotions and increased positive emotions across different measures. Reconstrual and repurposing interventions had similar effects. Importantly, planned exploratory analyses indicated that reappraisal interventions did not reduce intentions to practice preventive health behaviours. The findings demonstrate the viability of creating scalable, low-cost interventions for use around the world

A global experiment on motivating social distancing during the COVID-19 pandemic

Significance Communicating in ways that motivate engagement in social distancing remains a critical global public health priority during the COVID-19 pandemic. This study tested motivational qualities of messages about social distancing (those that promoted choice and agency vs. those that were forceful and shaming) in 25,718 people in 89 countries. The autonomy-supportive message decreased feelings of defying social distancing recommendations relative to the controlling message, and the controlling message increased controlled motivation, a less effective form of motivation, relative to no message. Message type did not impact intentions to socially distance, but people’s existing motivations were related to intentions. Findings were generalizable across a geographically diverse sample and may inform public health communication strategies in this and future global health emergencies. Abstract Finding communication strategies that effectively motivate social distancing continues to be a global public health priority during the COVID-19 pandemic. This cross-country, preregistered experiment (n = 25,718 from 89 countries) tested hypotheses concerning generalizable positive and negative outcomes of social distancing messages that promoted personal agency and reflective choices (i.e., an autonomy-supportive message) or were restrictive and shaming (i.e., a controlling message) compared with no message at all. Results partially supported experimental hypotheses in that the controlling message increased controlled motivation (a poorly internalized form of motivation relying on shame, guilt, and fear of social consequences) relative to no message. On the other hand, the autonomy-supportive message lowered feelings of defiance compared with the controlling message, but the controlling message did not differ from receiving no message at all. Unexpectedly, messages did not influence autonomous motivation (a highly internalized form of motivation relying on one’s core values) or behavioral intentions. Results supported hypothesized associations between people’s existing autonomous and controlled motivations and self-reported behavioral intentions to engage in social distancing. Controlled motivation was associated with more defiance and less long-term behavioral intention to engage in social distancing, whereas autonomous motivation was associated with less defiance and more short- and long-term intentions to social distance. Overall, this work highlights the potential harm of using shaming and pressuring language in public health communication, with implications for the current and future global health challenges

A global experiment on motivating social distancing during the COVID-19 pandemic

Finding communication strategies that effectively motivate social distancing continues to be a global public health priority during the COVID-19 pandemic. This cross-country, preregistered experiment (n = 25,718 from 89 countries) tested hypotheses concerning generalizable positive and negative outcomes of social distancing messages that promoted personal agency and reflective choices (i.e., an autonomy-supportive message) or were restrictive and shaming (i.e. a controlling message) compared to no message at all. Results partially supported experimental hypotheses in that the controlling message increased controlled motivation (a poorly-internalized form of motivation relying on shame, guilt, and fear of social consequences) relative to no message. On the other hand, the autonomy-supportive message lowered feelings of defiance compared to the controlling message, but the controlling message did not differ from receiving no message at all. Unexpectedly, messages did not influence autonomous motivation (a highly-internalized form of motivation relying on one’s core values) or behavioral intentions. Results supported hypothesized associations between people’s existing autonomous and controlled motivations and self-reported behavioral intentions to engage in social distancing: Controlled motivation was associated with more defiance and less long-term behavioral intentions to engage in social distancing, whereas autonomous motivation was associated with less defiance and more short- and long-term intentions to social distance. Overall, this work highlights the potential harm of using shaming and pressuring language in public health communication, with implications for the current and future global health challenges