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Carga de trabalho do enfermeiro de família na gestão da doença crónica : um contributo para a construção de uma matriz de referência para a dotação segura
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Enquadramento: A doença crónica é uma condição de saúde que se manifesta cada vez com maior expressão a nível mundial. As doenças crónicas como a diabetes, doenças cardiovasculares, entre outras afetam oito em cada 1dez pessoas com mais de 65 anos na Europa, e cerca de 80% dos orçamentos de saúde em toda a EU são gastos no tratamento destas doenças. O aumento das doenças crónicas tem impacte na vida das populações e coloca exigências e desafios aos sistemas de saúde e aos seus profissionais. Os cuidados de enfermagem podem e contribuem substancialmente, para a redução da morbimortalidade e para a eficiência dos sistemas de saúde. A carga de trabalho desajustada tem vindo a ser associada a eventos adversos, nomeadamente à probabilidade do aumento do número de mortes, aumento de infeções do trato urinário, úlceras por pressão, infeções respiratórias, insatisfação com os cuidados dos enfermeiros por parte dos utentes, insatisfação profissional e fracos resultados das instituições de saúde. Neste sentido, a dotação segura de enfermeiros relaciona-se com a prestação de cuidados seguros, de qualidade e de elevada complexidade, numa diversidade de contextos. Objetivos: O presente estudo pretendeu a construção de uma matriz orientadora para a determinação da dotação segura de Enfermeiros de Família (EF), considerando a carga de trabalho associada à dimensão dos cuidados à pessoa com doença crónica em contexto dos CSP. Definiram-se como objetivos centrais da investigação: construir e validar um instrumento que permitisse identificar as intervenções realizadas pelos EF na consulta à pessoa com doença crónica; identificar preditores da carga de trabalho; determinar a carga de trabalho na consulta; desenvolver um modelo de previsão da carga de trabalho e construir uma matriz de referência para a dotação segura de EF para a gestão da doença crónica. Metodologia: No propósito de alcançar os resultados pretendidos elaborou-se um desenho de investigação constituído por três etapas designadas por: base do projeto, edificação e consolidação do projeto. Em cada etapa foram realizados estudos nos quais se adotaram metodologias e instrumentos distintos. Na etapa 1, realizou-se um estudo em dois momentos: construção e validação do instrumento de avaliação da carga de trabalho dos enfermeiros de família, para tal recorreu-se à técnica de Delphi e, na verificação da aplicabilidade prática através de um estudo piloto de cariz quantitativo, descritivo exploratório, numa amostra de 16 enfermeiros de família e 196 pessoas com doença crónica (DM, HTA, HIPO). Na etapa 2 realizou-se um estudo eminentemente quantitativo, transversal e analítico com o qual se pretendeu identificar as intervenções realizadas pelos EF na consulta à pessoa com doença crónica e determinar a consequente carga trabalho. Recorreu-se a uma amostra de 509 pessoas portadoras de doença crónica inscritos no ACeS com diagnóstico ativo de doença, e 50 EF em exercício em unidades de saúde familiar e unidade de cuidados de saúde personalizados. Na etapa 3 concretizou-se um estudo eminentemente qualitativo com recurso a grupos focais, pretendeu-se validar uma fórmula de cálculo de horas seguras para a gestão da doença crónica e definir uma matriz de dotação segura. Resultados: Na primeira etapa da investigação construiu-se um instrumento designado por Instrumento de Avaliação da Carga de Trabalho do Enfermeiro de Família (IACTENFF). O instrumento é composto por cinco dimensões que correspondem à abrangência da atuação dos EF em contexto dos CSP. Validou-se o conteúdo do instrumento e verificou-se a aplicabilidade prática das grelhas IACTENFF-CE-DIA; IACTENFF-CE-HTA; IACTENFF-CE-HIPO que constituem a dimensão da Gestão da Doença Crónica (GDC). Verificou-se que mais de 90% das intervenções dos EF estavam previstas no instrumento o que permite determinar a carga de trabalho. Na etapa 2 foram identificadas as intervenções que EF realiza no âmbito da gestão da doença crónica (AC1, AC2, AC3). A carga de trabalho do EF na consulta à pessoa com doença crónica foi definida por intervenções do tipo avaliar, ensinar, monitorizar, acolhimento, procedimentos de continuidade de cuidados entre outros. Estas intervenções permitem identificar a dimensão dos cuidados assistenciais e não assistenciais, sendo que os cuidados assistenciais contribuem de forma mais significativa para a carga de trabalho. A carga de trabalho é traduzida pelo tempo de consulta para cada área clínica correspondendo ao tempo médio de 44,4 min (AC1), 43,8 min (AC2) e 35,5 min (AC3). Foram gerados modelos de previsão do cálculo da carga de trabalho a partir das intervenções realizadas no domínio assistencial e não assistencial. Verificou-se uma distribuição equitativa da carga de trabalho pelas respetivas áreas clínicas do EF âmbito do ACeS. Na última etapa da investigação foi validada a proposta de fórmula que permite determinar o peso da gestão da doença crónica na carga total de trabalho do EF, determinou-se o valor de 772h/anuais como horas seguras para a gestão da doença crónica. Conclusão: A evidência comprovou que o instrumento IACTENFF – Gestão de Doença Crónica (GDC) é válido. Os modelos de previsão de carga de trabalho gerados podem servir de referência para determinar a composição das equipas de enfermagem, principalmente no contexto de USF/UCSP. A matriz de dotação pode servir de referência e ser utilizada ao nível micro (no contexto de unidade funcional), a nível macro (no contexto de ACeS) ou a nível nacional, na medida em que identifica valores de horas seguras. A utilização de instrumentos precisos para determinar o dimensionamento das equipas de enfermagem nas USF/UCSP poderá permitir ao enfermeiro prestar cuidados seguros e de qualidade. Estes resultados são um passo na discussão de como organizar a prestação de cuidados de saúde, principalmente sobre como determinar o tamanho adequado de uma equipa de enfermagem. A organização dos cuidados de saúde é um assunto complexo, que exige estudos direcionados no sentido de melhorar o cuidado à pessoa com doença crónica.
Framework: Chronic disease is a health condition with increasing expression worldwide. Chronic diseases such as diabetes, cardiovascular diseases, among others, affect 8 out of 10 people over 65 in Europe and account for around 80% of healthcare budgets across the EU. The increase in chronic diseases has an impact on the lives of populations is a increasing challenge to health systems and their professionals. Nursing care contributes substantially to the reduction of morbidity and mortality and to the efficiency of health systems. The inadequate workload has been associated with adverse events, namely the probability of an increase in mortality, urinary tract infections, pressure ulcers, respiratory tract infections, patients' dissatisfaction with nurses' care, professional dissatisfaction and poor results of health institutions. As such, the safe allocation of nurses is related to the provision of highly complex, safe quality care, in a variety of contexts. Objectives: This study aimed to build an oriented matrix that helps to determine the safe allocation of Family Nurses, taking into account the workload associated with the different facets of care required for the person with chronic disease in the context of Primary Health Care (PHC). The main research objectives ware defined as: to build and validate an instrument that allows identifying the interventions carried out by Family Nurses in the consultation of chronic diseases; to identify workload predictors; to determine the workload in a consultation; to develop a workload forecast model and build a reference matrix for the safe allocation of Family Nurses for the management of chronic diseases. Methodology: In order to achieve the intended results, a research plan was crafted consisting of three stages: project base, construction and project consolidation. At each stage, the studies were conducted adopting different methodologies and instruments. In phase 1, a study was performed in two steps: construction and validation of the Family nurses’ workload assessment instrument, verified through the Delphi technique. Its practical applicability was tested through a pilot study of a quantitative, descriptive and exploratory nature, in a sample of 16 family nurses and 196 people with chronic disease (diabetes [AC1], hypertension [AC2], hypocologalation [AC3]). In phase 2, a quantitative, transversal, and analytical study was done, aimed at identifying the interventions performed by Family Nurses during the consultation of the person with a chronic disease, to determine the consequent associated workload. The sample consisted of 509 people with chronic disease enrolled in the ACeS with an active diagnosis of disease, and 50 Family Nurses working in USF/UCSP. In phase 3, a qualitative study was conducted using focus groups, with the purpose of validating a formula for calculating the safe number of hours for the management of chronic disease and creating a safe allocation matrix. Results: In the first stage of research, an instrument was built to assess the workload of the Family Nurse - IACTENFF. The instrument is composed of five facets that represents the scope of the practice of a Family Nurses in PHC. The content and layout of the instrument was validated and the practical applicability of the IACTENFF-CE-DIA; IACTENFF-CE-HTA; IACTENFF-CE-HIPO grids was verified, in what constitutes the Chronic Disease Management (CDM) facets. It was found that over 90% of the interventions provided by Family Nurses were predicted by the instrument. This means that the instrument can predict a family nurses’ workload. In step 2, the interventions that the Family Nurse performs in the context of chronic disease management were identified (AC1, AC2, AC3). The Family Nurse's workload when consulting a person with a chronic disease is characterized by interventions such as evaluation, teaching, monitoring, welcoming, continuity of care procedures, among others. These interventions made it possible to identify the dimensions of assisted and non-assisted care, the assisted care being the one that contributes more significantly to the workload. The workload can be seen as the mean consultation time for each clinical area 44,4m (AC1) 43,8 m (AC2) and 35,5 m (AC3). Workload calculation forecast models were generated. An equitable distribution of the workload among the respective clinical areas of Family Nurses was found. In the last stage of research, the proposal for the formula that determines the weight of chronic disease management in the total workload of family nurses was validated, and the value of 772h/annually was defined as the number of safe hours for the management of the chronic disease. Conclusion: Evidence proved that the instrument IACTENFF - Management of Chronic Disease (MCD) is valid. The workload forecast models generated can serve as a reference to determine the composition of nursing teams, especially in a USF/UCSP context. The allocation matrix can serve as a reference to be used at the micro level (in the context of a Health Unit), at the macro level (in the context of an ACeS) or at the national level, insofar as they identify safe hour values. The use of precise instruments to determine the size of nursing teams in USF/UCSP allows nurses to provide safe and quality care. These results are a step in the discussion of how to organize Health Care, especially on how to determine the correct size of a Nursing team. The correct organization of Health Care is a complex subject, which will still demand directed study to allow for better and better care of the person with a chronic disease.
Framework: Chronic disease is a health condition with increasing expression worldwide. Chronic diseases such as diabetes, cardiovascular diseases, among others, affect 8 out of 10 people over 65 in Europe and account for around 80% of healthcare budgets across the EU. The increase in chronic diseases has an impact on the lives of populations is a increasing challenge to health systems and their professionals. Nursing care contributes substantially to the reduction of morbidity and mortality and to the efficiency of health systems. The inadequate workload has been associated with adverse events, namely the probability of an increase in mortality, urinary tract infections, pressure ulcers, respiratory tract infections, patients' dissatisfaction with nurses' care, professional dissatisfaction and poor results of health institutions. As such, the safe allocation of nurses is related to the provision of highly complex, safe quality care, in a variety of contexts. Objectives: This study aimed to build an oriented matrix that helps to determine the safe allocation of Family Nurses, taking into account the workload associated with the different facets of care required for the person with chronic disease in the context of Primary Health Care (PHC). The main research objectives ware defined as: to build and validate an instrument that allows identifying the interventions carried out by Family Nurses in the consultation of chronic diseases; to identify workload predictors; to determine the workload in a consultation; to develop a workload forecast model and build a reference matrix for the safe allocation of Family Nurses for the management of chronic diseases. Methodology: In order to achieve the intended results, a research plan was crafted consisting of three stages: project base, construction and project consolidation. At each stage, the studies were conducted adopting different methodologies and instruments. In phase 1, a study was performed in two steps: construction and validation of the Family nurses’ workload assessment instrument, verified through the Delphi technique. Its practical applicability was tested through a pilot study of a quantitative, descriptive and exploratory nature, in a sample of 16 family nurses and 196 people with chronic disease (diabetes [AC1], hypertension [AC2], hypocologalation [AC3]). In phase 2, a quantitative, transversal, and analytical study was done, aimed at identifying the interventions performed by Family Nurses during the consultation of the person with a chronic disease, to determine the consequent associated workload. The sample consisted of 509 people with chronic disease enrolled in the ACeS with an active diagnosis of disease, and 50 Family Nurses working in USF/UCSP. In phase 3, a qualitative study was conducted using focus groups, with the purpose of validating a formula for calculating the safe number of hours for the management of chronic disease and creating a safe allocation matrix. Results: In the first stage of research, an instrument was built to assess the workload of the Family Nurse - IACTENFF. The instrument is composed of five facets that represents the scope of the practice of a Family Nurses in PHC. The content and layout of the instrument was validated and the practical applicability of the IACTENFF-CE-DIA; IACTENFF-CE-HTA; IACTENFF-CE-HIPO grids was verified, in what constitutes the Chronic Disease Management (CDM) facets. It was found that over 90% of the interventions provided by Family Nurses were predicted by the instrument. This means that the instrument can predict a family nurses’ workload. In step 2, the interventions that the Family Nurse performs in the context of chronic disease management were identified (AC1, AC2, AC3). The Family Nurse's workload when consulting a person with a chronic disease is characterized by interventions such as evaluation, teaching, monitoring, welcoming, continuity of care procedures, among others. These interventions made it possible to identify the dimensions of assisted and non-assisted care, the assisted care being the one that contributes more significantly to the workload. The workload can be seen as the mean consultation time for each clinical area 44,4m (AC1) 43,8 m (AC2) and 35,5 m (AC3). Workload calculation forecast models were generated. An equitable distribution of the workload among the respective clinical areas of Family Nurses was found. In the last stage of research, the proposal for the formula that determines the weight of chronic disease management in the total workload of family nurses was validated, and the value of 772h/annually was defined as the number of safe hours for the management of the chronic disease. Conclusion: Evidence proved that the instrument IACTENFF - Management of Chronic Disease (MCD) is valid. The workload forecast models generated can serve as a reference to determine the composition of nursing teams, especially in a USF/UCSP context. The allocation matrix can serve as a reference to be used at the micro level (in the context of a Health Unit), at the macro level (in the context of an ACeS) or at the national level, insofar as they identify safe hour values. The use of precise instruments to determine the size of nursing teams in USF/UCSP allows nurses to provide safe and quality care. These results are a step in the discussion of how to organize Health Care, especially on how to determine the correct size of a Nursing team. The correct organization of Health Care is a complex subject, which will still demand directed study to allow for better and better care of the person with a chronic disease.
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Keywords
Enfermeiros de saúde da família Carga de trabalho Doença crónica Modelos de cuidados Dotação de recursos para cuidados de saúde Equipa de enfermagem Family nurse practitioners Workload Chronic disease Health care models Health care rationing Nurse team
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Without CC licence